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DATA PRIVACY ADVISORY <br />In accordance with Minneso ta 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 C:ty of Orono or any of its departments <br />may require you to furn ish 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 M i nnesota 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 Last <br />Address <br />MN 5S"39l <br />City State Zip <br />Signature <br />Variance Application -May 2016 <br />Page 10 #3872 <br />Phone <br />RECEIVED <br />SEP 2 1 2016 <br />CITY OF ORONO