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� r � ' <br /> . • ..::�; <br /> .�-::,:_ <br /> + ���� <br /> a �-►'.....f:�= <br /> �.«: ...�.�,.,�: <br /> :s.: � �,.ens.r�-*z. <br /> �� �. �-.��-- �i��� O� ���1�� <br /> 3"'��r>*��^' �`� <br /> .�s-s,���.��'.� <br /> #;� <br /> �" Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> � <br /> � - � . � On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04 , Subd. 2, "Rights of subjects of <br /> data", we would like to inform you that your request for a permit or <br /> I.icense from the City of Orono or any of its departments may require <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or Iicense. <br /> 3. The information may be shared with other Iocal , s`ate or <br /> federal agencies to the extent necessary to process the permit or <br /> Iicense. <br /> 4. If your requested permit or Iicense requires Councii actior. <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to rev�ew private <br /> data on yourself. <br /> 6. Your full. name is required to process this application or <br /> permit. <br /> � <br /> �'��r_ ��; , �-��� �t� r�� ���'i; �.--�. _. �� <br /> First Middle ?�ast . <br /> � � - ' - '" ' \ rt �R._ <br /> ��L.I,.L'n .\I r � � �� .�._ `f\,`:L� <br /> Address <br /> r. � <br /> � �'�j, , .�JI ,�. �� .�>l�. �� <br /> City State Zip <br /> ,- <br /> E _ - r', .:� i <br /> Phone <br /> I understand my rights as stated above. <br /> � �/� _ � .�.,' ,L'. ` ��'���I._��� <<� <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&F[NANCE—473-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSING <br />