Building Code Board of Appeals Agenda and Packet 2019 04 18 CANCELLED

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Cityo f Louisville COLORADO • SINCE 1 8 i s Submit this form to the Chief Building Official in the Department of Planning and Safety, Louisville City Hall, 749 Main Street, Louisville, Colorado, 80027. AFFIDAVIT This affidavit certifies that I, � iv n-1 L�� ) (Name) S yyn-c� (-4. "k Ac r committed one or more acts prohibited by the City's building code (Contractor Name and Lic. #) , hereby allege that and request that the City make a motion to the Building Code Board of Appeals (Board) to schedule a hearing to consider an administrative remedy of temporary suspension or permanent revocation of the license or registration. In signing below, I acknowledge that the City may not make the motion to the Board if my complaint cannot be verified by the City Building Official. I hearby swear or affirm that the facts and statements set forth below are true and correct to the best of my knowledge and belief. Signature of Complainant: Physical Address of Complainant: Mailing Address: Date: ' 3/11 ,S6 - ' • Z. IA / c� ' 7 (Street, City, State, Zip) 1r� Business Address Phone: A;41 Residence Phone: 3i Fax: Adig! Email Address: 71.bI4f4.4�,�/�7 1047 STATE OF COLORADO COUNTY OF BOULDER Before me, �r I ' f , a notary public, authorized to administer oaths, in and for said State of Colorado, personally appeared (5-V !!11_ whose name is subscribed to the foregoing Complaint Affidavit, and who affirms, said statements are true and he/she acknowledges for execution of said instrument to be of their own free act and voluntary deed for the uses and purposes therein set forth. Subscribed and affirmed before me this }— day of `"ct.Y" 20 CAROL HANSON NOTARY PUBLIC STATE OF COLORADO NOTARY ID 20034041035 MY COMMISSION EXPIRES DECEMBER 4 2019 (Seal) Notary Public Signature