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Electronic Copy <br />DATq PRIVACY ADVISORY <br />In accordance with Minnasota State Statute 13.04 Righ[s of Subjeds of Data, Subd 2, 'Tennessen waming", we <br />would Ilke to Inform you that your request for a permit or license From tho City of Orono or any of its departments <br />may requlre you to furnisb cerN�iin prlvate or confidentiai information. <br />You are notified thaC <br />1. <br />2. <br />3. <br />4. <br />5. <br />The information you furnish will be used to determine your qualification for the permit or license <br />requested. <br />You may refuse to supply data, but refusal may require thaf the City deny the permit or license. <br />The information may be shared with other local, slate or federal agencies to the extent necessary <br />ro process the permit or license. <br />If your requested permit or license requires Council action to approve, some information may <br />become public. <br />You have certain riyhts under Minnesota Sta�e Statute 13.04 (see follawing page) to review private <br />data on yourself. <br />6. Your full name is required to process this application or permit. <br />Alexander Ugorets <br />First Middle Last <br />410 llth Ave South <br />Address <br />Hopkins <br />City <br />MN 55343 <br />State Zio <br />I undc i� d my rights �is s�atad above. <br />� _�� � <br />' �nature <br />Land Use Appllcalion — May 2015 <br />Page !1 <br />(612)363-3321 <br />Phone <br />FtECEIVED <br />sa� i a 20�7 <br /># 3 9 03 ��N OF ORONO <br />