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DAT A PRIVACY ADVISORY <br />In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessen <br />warning", we would like to inform you that your request for a permit or license from the City of Orono or <br />any of its departments 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 you r qualification for the pe rmit or <br />license requested. <br />2. You may refuse to supply data, but refusal may require that the City deny the permit or <br />license. <br />3. The information may be shared with other local, state or federal agencies to the extent <br />necessary to process the permit or license. <br />4. If your requested permit or license requires Council action to approve , some information <br />may become public. <br />5. You have certain rights under Minnesota State Statute 13.04 (see following page) to <br />review private data on yourself. <br />6. Your full name is required to process this application or permit. <br />~o rtrl :f /\:t--o~b D v UL} ---- <br />First Middle Last <br />~D /D -- <br />Address <br />5539( <br />Zip <br />Variance Application Updated : January 31, 2012 <br />-15 - <br />#3567 <br />Phone <br />RECEIVED <br />JUL 1 7 2012 <br />CITY OF ORONO