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DATA PRIVACY ADVISORY <br /> In accordance with Minnesota Slate 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 /> o cr ' 4S G‘A, r'Mt..t <br /> First Middle J Last <br /> Z lit S t o ?Of if\.---i". KC4 <br /> Address <br /> ro ✓iv M � SS�� / c1 -)) 1 °7(1 <br /> crty State Zip Phone <br /> I understand my rights as stated above. <br /> ett <br /> Variance Application—Jemmy 2017 RECEIVED <br /> Page 14 <br /> AUG 2 3 2017 <br /> * 396 ' <br /> `' CITY OF ORONO <br />