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DA7A PRIYAGY ADVISORY <br /> In accordance with Minnesota Stete Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessen waming",we <br /> would like to inform you that your reQuest for a peRnit or license from the City of Orono or any of its departments <br /> may require you to fumish certain private or confldential information. <br /> You are notified that: <br /> 1. The intormadon you fumish will be used to deterrnine your quafification for the permit or Iicense <br /> requested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny the perrnit or(icense. <br /> 3. The information may be shared with other focal,state or federal agencies to the extent necessary <br /> to process the permit or license. <br /> 4. If your requested permit or license requires Counci! action to approve, some information may <br /> become public. <br /> 5. You have certain rights under Minnesota 5tate Statute 13_04(see foftowing page}to review private <br /> data on yourself. <br /> 6. Your fuil name is required to process this application or peRnit <br /> �i��,�� J a `t n/ /V'tc� �s , _. <br /> F1rst Middle Last <br /> ��7� ��ll--�� <br /> Address <br /> ��v S.vS'.3 �Z-�?SD'�(�D <br /> Ciry Siate Zip Phone <br /> I understand my rights as sta#ecf above. � � <br /> Signature <br /> �ECEIVED <br /> Variance AppliceNan—May 207fi � � � � <br /> SEP 21 2�5� <br /> Pege 1 Q � <br /> G1�1(OF ORONO <br />