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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 />--ruM f'b W V'. <br />First Middle Last <br />Address <br />)12\u,y b <br />City <br />MAJ <br />' State <br />G\) --8\ ~ J zssr;~ <br />Phone <br />I ";ii;3712i) , <br />Signature ~ <br />Variance Application -May 2016 <br />Page 10 <br />#3845 <br />RECEIVED <br />JU N 2 1 2016 <br />CITY OF ORONO