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DATA PRIVACY ADVISORY <br />In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessen warning", we <br />would like to inform you that your request for a permit or license from the City of Orono or any of its departments <br />may require 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 qualification for the permit or license <br />requested. <br />2. You may refuse to supply data, but refusal may require that the City deny the permit or license. <br />3. The information may be shared with other local, state or federal agencies to the extent necessary <br />to process the permit or license. <br />4. If your requested permit or license requires Council action to approve, some information may <br />become public. <br />5. You have certain rights under Minnesota State Statute 13.04 (see following page) to review private <br />data on yourself. <br />6. Your full name is required to process this application or permit. <br />(1L a <br />First Middle Last <br />I understand my rights as stated above. <br />re <br />Variance Application — January 2017 <br />RECEIVED <br />JAN 1 12017 <br />Page 14 <br />3901 CITr` OF ORONO <br />