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DATA PRIVACY ADVISORY <br /> In accordance with Minnesota 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 City of Orono or any of its departments <br /> may require you to furnish 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 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 /> IDA1) I I') A- 6E14)4I'+CA.4, ro 444.. <br /> First Middle Last <br /> 1 3 5 rili>-v ti bki- {- I <br /> Address <br /> (-4/4-0-14/til 44 fJ 5 3 / % 64,2-Phonef / 6 j/1rd <br /> (/ <br /> City State Zip <br /> I understand my rig as stated -Xe. <br /> Signatu <br /> Variance Application—May 2016 <br /> Page 10 <br />