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DAT A PRIVACY ADVISORY <br />In accordance with Minnesota State Statute 13 .04 R ights of Subjects of Da t a , 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 requ ire you to furnish certain priva te 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 />First Middle <br />Address <br />O e.oN o IA N <br />City State <br />Variance Application -January 2017 <br />Last <br />55~1 <br />Zip <br />"t S'l. · ':n ~ . 19,11 <br />Phone <br />Pag e 14 Jt 39 97 <br />RECEIVED <br />DEC ·, 3 ZUH <br />CITY OF ORONO