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� w <br /> � � ���C`�'o� O��I1T� <br /> Post Office Box 66•Crysial Bay.Minnesota 55323•Municipal Offices <br /> ! <br /> • _ � � pn the North Shore of Lake Minnetonka _ <br /> DATA PRSVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of sub ern�t o= <br /> data", we w o u l d l i k e t o inform you that your request for a P r e u i r e <br /> license from the City af Orono ar any of its depar tmen t s m a y Q <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> l. The information you furnish will be used to determine your <br /> qualification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared witht�oth��r eSscthe permit or <br /> federal agencies to the extent necessary P <br /> license. <br /> 4. If your requested permit or Iicense requires Councii ac��or_ <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> �.t�� �� �Q v� �� SC. Gl a� v� ic �n Q,- - <br /> First <br /> Middle Last Q <br /> � �� o �or -E �-. S �va�'- �l� • <br /> Address <br /> �1 U Li h P F �vt �V S,! � �y <br /> City State Zlp <br /> �1'] 2 37J3 . � <br /> Phone <br /> I understand my rights as stated above. <br /> �� ��� <br /> Signature ' ' • � <br /> BUILDING&Z�NING—473-7357 • ADMIIVISTRATION&FiNANCE—473-7358 <br /> � PUBLIC WORKS—473 7359 <br /> pSSESSING <br />