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�.� �t.�'+� <br /> � F ��y t�� ~"� <br /> � <br /> `� � <br /> , . ;yf .; ;z , CI'r1' of �R►OI�O <br /> ,�, t � <br /> ' „k�, ._ ' _'� �' Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices <br /> ,;�.�� �. <br /> " ��'� y� � "� On the North Shore of Lake Minnetonka <br /> c3� �, e� <br /> �.•. <br /> .3;�'; <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of <br /> data", we would Iike to inform you that your request for a permit or <br /> license 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 3icense. <br /> 3. The information may be shared with other iocal , state or <br /> federal. agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or Zicense requires Counci3. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review pri�a�� <br /> data on yourself. <br /> 6. Yaur full. name is required to process this applicatian or <br /> permit. <br /> ��E..v s �.�� �T� E .v, ,� G� w s t <br /> � <br /> h <br /> �� 0 2`� cS �vvi � S �� f w� � - <br /> First' Middle Last <br /> 3 � 55 �'�� � i� l riv J� V � ' <br /> Address <br /> ' '� 5 <br /> `��( . � �'c ,� '� c� ��t. ,, y�'t i �^ �, . S S- � ` - <br /> City State Zip <br /> yyt� -i s � � <br /> Phone <br /> I understand my rights as stated above. <br /> � \ <br /> ) , � „ <br /> � <br /> ' � <br /> ,� .,:'r�-- ' 1;-?�....3 <br /> Signature ;'"! <br /> � <br /> BUILDING&ZONING—473-7357 • ADMINISTRATIO[Y&FINANCE—473-7358 • PUBLIC WORKS—473-7359 <br /> ASSESSING - <br />