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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 /> K <br /> First Middle Last <br /> a'.140 SK-A-1 -1 if)Oc l K—1. <br /> Address <br /> L+r ( o iz.,.. 1;'1W SS 33 <br /> City State Zip Phone <br /> I Ode stand my rights tate ove. fJ <br /> v r \ T 11V\ t-- <br /> W <br /> Si nature <br /> RECEIVED <br /> SEP 2 O 2017 <br /> Variance Application-January 2017bt +^� <br /> Page 14 <br /> r ® - CITY OF ORONO <br /> t•, <br />