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DATA PRIVACY ADVISORY <br /> In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, 'Tennessee warning",we <br /> would like to inform you that your request for a pemlit 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 /> 7l/Chellt/4"742--.1 1,4 <br /> Fire eJs.� fi c ie ,.;Last <br /> 3o /U 4.s%..e-4.,_ ),-,f.(- rzn - ss.??1 <br /> Address <br /> i✓`41 zdek-r0 /174/ .5T.5—s)71 6/2 Yvo- <br /> City State Zip Phone <br /> (/Z 9f/--5¢2 6 <br /> I understand my rights as stated above. <br /> r <br /> / ;xi J <br /> Signature, t <br /> Variance Application_January 2017 RECEIVED <br /> Pape 14 <br /> AUG 23 21111 <br /> 3967 CITY OF ORONO <br />