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DAfi <br />In accordance with Winnesota State Statute 13.04 Rights of Subjeca of Data, Subd. 2, 7annessen warning", we <br />would like to lnfcrm you that your request for a permit or license from the City of Orono or any of its departments <br />may require you to furnish certain private or confidential Information. <br />You ars notftd that: <br />The information you furnish wilt to used to determine your quaalificatlon 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 CouncA action to approve, some Information may <br />become public. <br />5. You have certaln rights under Minnesota State Statute 13,04 (see dowing page) to review private <br />data on yourself. <br />B. Your full name is required to procassss this application or permit. <br />JUSTIN MICHE4L OW AL <br />First Middle Last <br />PO BOX 881 <br />Address <br />ST CLOUD MN 56302 320 252 9400 <br />City State Zip Phone <br />I understand my rights qs3 started above. <br />RECEIVED <br />OCT 14 2016 <br />V808 aw Ap ksibn -• 141ey 2416 <br />Page 16 # 3879 <br />CM OF aRallo <br />