HomeMy WebLinkAboutbld-23-003986 a
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ONE & TWO FAMILY ONLY-`BUILDING PERMIT
Town of Yarmouth Building Department
1146 Route 28, South Yarmouth,MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836 l 4;,%.
Massachusetts State Building Code,780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish ::: :;.:-.•,
a One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: &3LD�3-0 ftp Date Applied:
rThE�� C3 - 1 - -,3 -CEIVED
Building Official(Print Name) Signature I Da N ?O 2023
SECTION 1:SITE INFORMATION h1
•
/1.1/ ropertyress:, 1.2 Assessors Map&Parcel Numbers i BUILDING DEPARTMENT
V �/`fl W l / By. ______________
1.1 a Is this an accepted street?yes L/ no Map Number Parcel Number
1.3 Zoning Information: 1.4 P erty Dimensions:
a«5
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
H
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: Outside Flood Zone?
— Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2. Ow er'pi:Accord:
II vv) rm L. ) A. oz66 °
I Name(Print) y Ci ,State,ZIP -
A w s s I n/1 ��f Qr1149 -COVI
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: I
/ /
1.11 " - C bi- ry t i'i
SECTION 4: ESTIMATE ONSTRUCTION COSDS
Item Estimated Costs: Official Use Only
•
(Labor and Materials)
1.Building $ 1. Building Permit Fee:$ I$o Indicate how fee is determined:
2.Electrical $ 1 Standard City/Town Application Fee
0 Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: J 55T,/J e
5.Mechanical (Fire \
Suppression) $ Total All Fees:$ \
6.Total Project Cost: $ . Check No. Check Amount: Cash ount:
/,/ 00 f 0 Paid in Full 111,Outstanding Balance e: ‘As \ 1
\A6
i
r SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervi or License(CSL) C —072/V Q f_CZ-
Jdr g tv) License Number Ex rati n Date
Name of CSL Holder
�2 A�./I i List CSL Type(see below) (�C
No.and Street ! Type Description
/i1
p C7//;,0 U Unrestricted(Buildings up to 35,000 cu.ft.)
/ 33"�� L(Ov R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
��g /�p- SF Solid Fuel Burning Appliances
fJ—(J`J(/bhtiekrititrugeitovetice I Insulation
Telephone Email address ,
qt, I D Demolition
5.2 4R gistered Hope Improvement Contractor(� �77oG I z
0>-1 ens r. ,tS 0 l 3
iC Com any Name or C egistrant Name HIC i egistration Number xp. ation Date
s ��l l� h lime 3Q,1 � G '!
�^an Street ‘6 '� �� /
`DO 2_,1n:5 Ra OLD/ a 2�_ C� Email address
City/Town, State,ZIP %��V Telephone hud rOn Nine renova kv Q
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes 0 No C
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize J/06' ' AMA.- ./10V/e4161(1 Aavt.e.5 geikon
to act on my behalf, in all matters relative to work authorized by this building permit application.
'ZII n I16 3
Print Owner's Na> (Electronic Signature) / /Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
�'�^0.-' b(cAc5c, -) 0__ 43
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.cov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
} —r = 1 Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA'02114-2017
ow"• www.mass.gov/dig
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information
� Please Print Legibly
Name (Business/Organization/Individual): �-o �) ✓�� ��
Address: 31 4(1"•:e_
City/State/Zip: l e ,3 I 11/44• 1 CZ 4 D Phone #: Z6Tr
Are you an employer?Check the appropriate box:
Type of project(required):
I. 1 a employer with employees(full and/or part-time).`
7. ❑New construction
_ am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp. insurance required.] 8. Remodeling •
3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ D olition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole
11.0 Electrical repairs or additions
proprietors with no employees.
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12. Plumbing repairs or additions
These sub-contractors have employees and have workers'comp. insurance.[ 13•El Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other
152,§I(4),and we have no employees. [No workers'comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify un• the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: //16/e
Phone#: 5'
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
TOWN OF YARMOUTH
o BUILDING DEPARTMENT
�0
aY MATTACY.CCS xd 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DA 1'h:
JOB LOCATION: I A /rc4 yor'Y) pr+
NAME STREET ADDRESS 'SECTION O1 TOWN
"HOMFOWNER"q,lI f ✓►/1 r1- &�t�.- Seil
NAME/ HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS
CITY OR TOWN STATE, ZIP CODE
The current exemption for `Homeowner' was extended to include owner-occupied dwellings of one or two units
and to allow such homeowners to engage an individual for hire who does not possess a license,provided that such
homeowner shall act as supervisor. (State Building Code Section 110 R5.1.3.1)
Definition of Homeowner:
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is or is intended to
be, a one or two family attached or detached structure assessory to such use and/or farm structures. A person who
constructs more than one home in a two-year period shall not be considered a homeowner;such"homeowner"shall
submit to the building official, on a form acceptable to the building official,that he/she shall be responsible for all
such work performed under the building permit. (Section 110 R5.1.3.1)
The undersigned `homeowner' assumes responsibility for compliance with the State Building Code and other
applicable codes, by-laws, rules and regulations.
The undersigned 'homeowner' certifies that he / she understands the Town of Yarmouth Building Department
minimum inspection procedures and requirements and that he / she will comply with said procedures and
requirements.
HOMEOWNER"S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL
Ch.142. Yes No
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent
h:homeownrlicexemp
,
TOWN OF YARMOUTH
1146 Route 28, South' Yarmouth, MA 02664
508-398-2231 ext. 1261 Fax 508-398-0836
Office of the Building Commissioner
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G. L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111/5
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at / ,4 n( 4-
Work Address
Is to be disposed of at the following location: n `_ r- 40/6;z5K)
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
///b/1_3
Signature of Applicant Date
Permit No.
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)name(s), address(es) and phone number(s)along with their certificate(s) of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year;need only submit one affidavit indicating current
policy information (if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02 1 1 4-20 1 7
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
•
1.orrirrfonweafth of Massachusetts
Division of Occupational Licensure
Board of Building 1�! utations and Standards
+ConstairS eervisor
CS-092681 * ires: 1211012023
JAMES E = •
t
80 AIRLAVE `+ <
SOUTH DEN
Commissioner agilie..1 it. c, a,
//� �ninm �✓i�iz itziirr�/�ial�/
Office of Consumer Affairs Busmen Reguiallon
Rel
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HOME IMPROVEII�E:NT DO�RACTOR � Oft
ls
• TYPE:U..0 itK1
Rec7+_sfratron �i
1 M9._ . +
HUDSON HOME 414VATICINI tic
JAMES HUDSON "e`
SO AIRLINE ROAt „:.
SOUTH DENNIS,MA o +
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(cs: TOWN OF YARMOUTH
v= ' ' .-• 1146 ROUTE 28,SOUTH YARMOUTH,MA 02664-4451
8-7-etiVED I ' - Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836
OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE
APPLICATION FOR
01 D KiN.0 , CERTIFICATE OF APPROPRIATENESS
Application is hereby made for issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Acts of 1973 as
amended,for proposed work as described below&on plans,drawings,photographs,&other supplemental info accompanying this
application. PLEASE SUBMIT 4 copies OF SPEC SHEET(S),ELEVATIONS,PHOTOS,&SUPPLEME TAL INFORMATION.
Check All Categories That Apply: Indicate type of Building: Commercial Residential
1)Exterior Building Construction: New Building Addition /Al(erations Reroof Garage
Shed Solar Panels Other:
2)Exterior Painting: Siding Shutters Doors Trim , /Other:
3)Sign-,,i;illboards: New Sign Change to Existing Sign
4)Miscv:neous Structures: Fence Wall Flagpole Pool , Other:
Please type or print legibly:
Address of proposed work: T/ A WA1fi
- tt Map/Lot# qt°11 3
Owner(s): FA:11 T/YIVINI 5 , , 7.....et40
Phone#:
All applications must be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address: Year built:
Email: referred notification method: Phone Email
Agent/contractor: I VI, If.K141)S P4 '-'1.4() ,,p(N.) YVTI‘t e/riC2V6111614hone#:94 71Q /1,),5-b
Mailing Address: la0 AfiLliike gOtt/e0 \ 501441 49.1kwis pia . 02/1.94o
Email: lilvtaftVILOV *OD teei-coq& LI file. AO/Preferred notification method: Phone r Email
Description of Proposed Work:
0 tie, 10 112 '''' ':ot 4-nily,R : OM/ #- '
0
*14C 32)91517 611 1 C 2,"
6 ki u
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, , 1114(1 tnil
Signed(Owner or agent): '.. Date: / /
Owner/contractor/agent is awe at a permit is required from the Building Department.(Check other departments,also.)
.. If application is approved,approval is subject to a 10-day appeal period required by the Act.
This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later.
`). All new construction will be subject to inspection by OKH.OKH-approved plans MUST be available on-site for framing&final inspections. 1
For Committee use only: /Approved Approved with Modifications Denied
Rcvd Date: t)131 1422 Reason for Denial:
Amount
Cash/CK#: -42,‘,Q
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Signed: c -- f,lek,/A
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Rcyci by: ,
PP MC
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45 Days: •
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Date Signed. II 4/23 7 '.-0 .--(.— ,,1.-- .e,-1--e-e.,,,,,C I
1
APPLICATION#:
TOWN OF.YARMOUTH
HEALTH DEPARTMENT
�''�•'` PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
G[-
Building Site Location: /A (,)-.1(? ycYlrOL24- e r4
r Proposed Improvement: 1Jr✓1 c,�( � ,\n�-c ic=1,11, ( (:-c ✓V 3L �
< CCSt ram( t ��'fc� ��c L. /
Applicant: �(,td J� /Yt�e__ q_p4A.Aci/V7 Tel. No.: 4 5•-
Address: r� C � '%�'` Date Filed: VZ6/Z3
**Ifyou would like e-mail notification of sign off,please provide e-mail address: kc)504/7011.4/W)c/A- r.
Owner Name: ' i it /rhr
Owner Address: /A 0, ' r Owner Tel. Z<� n 1q
7
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed) —
Note: Floor plans not required for decks, sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
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REVIEWED BY: ti, DATE: F7/6)
PLEASE NOTE
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Affidavit of Successor Trustee
EJF Revocable Trust, dated August 16, 2016
Being duly sworn,the undersigned states as follows:
1. The subject of this Affidavit is the EJF Revocable Trust,dated August 16,2016.
2. The Trust was established by Edward J. Fiore.
3. The name and address of the Trust's currently serving Trustee is as follows: William S.
Flynn, 20 Vincent Road,Mendon,MA 01756.
4. The former Trustee of the Trust was Edward J. Fiore.
5. The named successor Trustee,Norma D. Borelli, has declined to act.
6. The currently serving Trustee succeeded the former Trustee by reason of the death of
Edward J. Fiore on November 27, 2021. Attached are (1) a copy of his death certificate;
(2) the Trustee Declination to Serve of Norma D. Borelli; and (3)a copy of the pages of
the trust that appoint me to serve as successor Trustee.
7. The signatory of this Affidavit is the named successor Trustee and the currently serving
Trustee of the Trust and hereby declares under penalty of perjury that the foregoing
statements and the attached documents are true and correct.
8. Each photocopy of this Affidavit will have the same force and effect as any original, as
will any facsimile copy provided by Ingle Law, P.C., 9 Main Street, Southborough, MA
01772.
9. This Affidavit is signed below by the currently serving Trustee of the Trust.
IN WITNESS WHEREOF, as Affiant, I have executed this Affidavit in multiple counterpart
originals.
Date: /'_//9 17 i 1.J.�--
William S. Flynn,Tru ee of the EJF Revocable
Trust,dated August 16, 2016
, -
i .
MASSACHUSEITI S )
)ss.
COUNTY OF WORCESTER )
On this day, December 14, 2021, before me, the undersigned notary public,personally appeared,
William S.Flynn,proved to me through satisfactory evidence of identification,which was personal
knowledge,to be the person whose name is signed to the preceding Affidavit of Successor Trustee,
and acknowledged to me that she signed it voluntarily for its stated purposes.
71_,Ly.
.--
4/4'.
Tracey A. L. Ingle,Notary Public
My commission expires: February 27,2026
CTAEYRYA.
, pLu el NiGi cl_E
i COMMONWTRAN°
FAITH OF MASSACHUSETTS
'- MY COMMISSION EXPIRES 02/27/2026
Affidavit of Successor Trustee
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nil III C'nntmonr,ral,h of Massachusetts-
. Registry of Vital Records and Statistics State File if 2021 056214
d
CERTIFICATE OF DEATH
Registered d it $85
(i'O12019
Place of Death METROWFSST MED CTR-FRAMiNGIIAM UNION HOSPITAL, FRAMiNGIIAM, MA
Date olDeath NOVEMBER 27,2021 Age 85 IRS Ser MALE
Current Name FIORE , EDWARD J
Surname at Birth or Adoption FIORE. SSN --—1220
AKA
Date ofBirth JANUARY 04,1936 Birthplace SOMERVILLE, MASS ACIl(JSKITS
'F.
a Residence 17OAKRIDGE ROAD,HOLLiSTON,MASSACHUSETTS 01746
u. Race Education
W WHITE HIGH SCHOOLGRADUATE ORGED
;1Ivrind Status Occupation lndtcstry
WID0WE:D MANITACTIIRING MANAGER/MANIIFACTI'RING
Last Spouse-Last.First.Middle'Surname at Birth or Adoption) Decedent:U.S Petehsn(Most Recent)
FIORE, ANNE,M(MCDERMOTT) NO
Parent Name-Last,First Middle(Surnnneat Birth orAdoption) Birthplace
FIORE, CAMILLA (LANGONE) MASSACHUSETTS
1'arent Naive-Lea.First Middle(Sun winea,Birth orAdoptivnl Birthplace
FIORE, VICTOR(FIORE) ITAI Y
P,rrtI cause of Death-Sequentiullclistimmediatecanus'thenanrcecderecartsesthenuuderlyingcatve run• ,ai,a•r<r„=i..,:-,,:at.i•vr.
a,Ion Cat>x t I at ec,ndicier>re,atdnt:in dtat)
CARDIOPULMONARY ARREST —SEC.
b.Due to ar a,a cattse,p:cncen;
s RESPIRATORY DISTRESS —SEC.
-. r.flat to or it, ace�rpctncr of:
a
SEVERE ACIDOSIS --HRS.
Y, 1.Uric r.ar are zaanc ucncC wf;
ACUTE KIDNEY INJURY —DAYS
Part IL Other significant conditions contributing so death but not resulting in underlying cause Manner af Death
'
NATURAL
a
Timerrfl)eath 07:05 PM
Srsuit of lnjuri NO
Certifier SUC'IIANAN KANJANAPONG, MI) Lice(289192
Addl.. 115 LINCOI N STREET,FRAMINGHAM, MASSACHUSETTS 01702
Funeral l icensee'Designee KF,EFE M CHES MORE Lie#6563
1•ircilit)+'Addy. CHES MO RE FUN ERAL HOME,HOLLISTON,M:ASS ACHES E1'•CS
Immediate Disposition CREMATION
c Date of Immediate Disposition NOVEMBER 29,2021
PlaceAddress
WOODLAWN NORTH PURCHASE CEMETERIES ASSOC.,
825 N MAIN STREET,ATTLFJ3ORO, MASSACHUSETTS
Date ofRecord NOVEMBER 30.2021
Date nf.2nrendmcart -- CLERK. CITY OF FRAMINGHAM
DATEISSGED. NOYE BER30,2021
A true copy of record
• Attest: Elizabeth T.
rer}rs
i ,
Town Clerk
Holliston, A 0174
R-301 p.2 oft FIORE SFN:2021 056214
FRAMINGHAM 585
HOLLISTON 95
STATE VOL/PG:/
If U.S.uur veteran,spec fi•xar/conflict(s)
Branch ofm ilitary(most recent) Rank/otganimtion/ou ftlmost recent)
Date entered(most recent) Date Discharged(mcst recent) Service NUM her(most recent)
Place ofDeath Type Date ofPronowi ement Time of Pronouncement
HOSPITAL-INPATIENT —
RN/NP/PAPronouncement? Name oJRN/NP/PA Pronouncing Death Lie#
NO — —
R,V/NP/PA Employing Agamy or Institution Name of Physician or Medical Examine rnoti/iied
Was ME.NoiJied? Provider in charge ufpaticnI's cam iJ7ratcertifier
NO DEBORAH HMARKOWITZ, MD
AutopsvPerformcd? Findings availableforCause? Tobacco contribute to death? •Pregnancy Status,iffema le
NO — UNKNOWN —
Dateoflnjuty Time oflnjury Injury at Work? If Transportation Injury,specify:
Placeoj/njuty Location/Addressoflnjwy:
Describe How Injury Occurred
Expanded Race:WHITE
Ethnicity:AMERICAN
Inform ant Name Relationship
WI LIAM S FLYNN NEPHEW
Addr.20 VINCENT ROAD,MEND ON,MASSACHUSFTTS 01756
Date DispositionPennitIssued: NOVEMBER 29,2021 Board ojHealthA gent LISA A.FERGUSON
State Tracking No. 056214 Local Permit No. 21-591
Trustee Declination to Serve
The undersigned, Norma D. Borelli, is nominated as Trustee of the EJF Revocable Trust dated
August 16,2016. The undersigned declines to serve in this capacity.
I
giAttt_ Ol
Norma D. Borelli
MASSACHUSETTS )
/ ss.
COUNTY OF /Prie /(c��� _ )
On this day, 6(P01 aJ/, 2021, before me, the undersigned notary public, personally appeared
Norma D. Borelli, proved to me through satisfactory evidence of identification, which was
v.( , to be the person whose name is signed to the preceding Trustee
Declination to Serve,and acknowledged to me that she signed it voluntarily for its stated purposes.
oe v 4/ . ,Notary Public
G ES My commission expires: //4 .!/i/2—
11:N Way PUBLIC� weohfiIt Er_S6 m'
�• M January 22,2027
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Trustee Acceptance of Appointment
The undersigned, William S. Flynn, accepts appointment as Trustee of the EJF Revocable Trust,
dated August 16,2016.
William S.Flynn
MASSACHUSETTS )
)ss.
COUNTY OF WORCESTER )
On this day, December 14, 2021, before me, the undersigned notary public, personally appeared
William S.Flynn,proved to me through satisfactory evidence of identification,which was personal
knowledge, to be the person whose name is signed to the preceding Trustee Acceptance of
Appointment,and acknowledged to me that signed it voluntarily for its stated purposes.
re L. Ingle,Notary Public
My commission expires:February 27,2026
Article Three
Trustee Succession Provisions
Section 3.01 Resignation of a Trustee
A Trustee may resign by giving written notice to me. If I am incapacitated or deceased,a
resigning Trustee must give written notice to the trust's Income Beneficiaries and to any
other then-serving Trustee.
Section 3.02 Trustee Succession during My Lifetime
During my lifetime,this Section governs the removal and replacement of my Trustees.
(a) Removal and Replacement by Me
I may remove any Trustee with or without cause at any time. If a Trustee
is removed, resigns, or cannot continue to serve for any reason, I may
serve as sole Trustee, appoint a Trustee to serve with me, or appoint a
successor Trustee.
(b) During My Incapacity
During any time that I am incapacitated, the following will replace any
then-serving Trustee in this order:
Norma D. Borelli;
�-- William S.Flynn;then
Donna J.Flynn.
If I am incapacitated, a Trustee may be removed only for cause, and only
if a court of competent jurisdiction approves the removal upon the petition
of an interested party.
If I am incapacitated and no named successor Trustee has been designated,
the person appointed my conservator may appoint an individual or a
corporate fiduciary to serve as my successor Trustee.
All appointments,removals,and revocations must be by signed written instrument.
Section 3.03 Trustee Succession after My Death
After my death,this Section will govern the removal and replacement of my Trustees.
(a) Successor Trustee
I name the following,in this order,to serve as my successor Trustee after
my death,replacing any then-serving Trustee:
Norma D.Borelli;
William S. Flynn;then
Donna J.Flynn.
3-1
(b) Trustees of the Separate Trusts
The Primary Beneficiary of a separate trust created under this instrument,
upon attaining 35 years of age, may appoint himself or herself as a Co-
Trustee of his or her separate trust and may serve as the sole Trustee of the
trust.
If the interest of a beneficiary will be merged into a life estate or an estate
for years because the beneficiary is serving as sole Trustee,the beneficiary
must appoint a Co-Trustee to avoid this merger. Similarly,if the interest
of a beneficiary becomes or is likely to become subject to the claims of
any creditor or to legal process as a result of serving as sole Trustee, the
beneficiary must appoint an Independent Trustee to serve as Co-Trustee.
Notwithstanding the previous provisions, the Primary Beneficiary of any
trust administered as a Supplemental Needs Trust under this instrument
may not appoint himself or herself at any time as a Co-Trustee of his or
her separate trust, and may not serve as the sole Trustee of his or her
separate trust.
(c) Removal of a Trustee
A Trustee of any trust created under this instrument may be removed,with
or without cause, by the unanimous decision of all the trust's Income
Beneficiaries.
A Trustee may be removed under this Subsection only if the person having
the right of removal appoints an individual or a corporate fiduciary by the
effective removal date and the individual or corporate fiduciary
simultaneously commences service as Trustee. This appointed Trustee
may not be related or subordinate to the person or persons having the right
of removal within the meaning of Internal Revenue Code Section 672(c).
The right to remove a Trustee under this Subsection is not to be
interpreted as granting the person holding that right any of the powers of
that Trustee.
A minor or incapacitated beneficiary's parent or Legal Representative may
act on his or her behalf.
(d) Default of Designation
If the office of Trustee of a trust created under this instrument is vacant
and no designated successor Trustee is able and willing to act as Trustee,
the trust's Primary Beneficiary may appoint an individual or corporate
fiduciary that is not related or subordinate to the person or persons making
the appointment within the meaning of Section 672(c) of the Internal
Revenue Code as successor Trustee.
Any beneficiary may petition a court of competent jurisdiction to appoint
a successor Trustee to fill any vacancy lasting longer than 30 days. The
petition may subject the trust to the jurisdiction of the court only to the
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extent necessary to make the appointment and may not subject the trust to
the continuing jurisdiction of the court.
A minor or incapacitated beneficiary's parent or Legal Representative may
act on his or her behalf.
Section 3.04 Notice of Removal and Appointment
Notice of removal must be in writing and delivered to the Trustee being removed and to
any other then-serving Trustees. The removal becomes effective in accordance with its
provisions.
Notice of appointment must be in writing and delivered to the successor Trustee and to
any other then-serving Trustees. The appointment becomes effective at the time of
acceptance by the successor Trustee. A copy of the notice may be attached to this
instrument.
Section 3.05 Appointment of a Co-Trustee
Any individual Trustee may appoint an individual or a corporate fiduciary as a Co-
Trustee. This Co-Trustee serves only as long as the appointing Trustee serves,or as long
as the last to serve if more than one Trustee appointed the Co-Trustee. This Co-Trustee
will not become a successor Trustee upon the death, resignation, or incapacity of the
appointing Trustee, unless appointed under the terms of this instrument. Although this
Co-Trustee may exercise all the powers of the appointing Trustee,the combined powers
of this Co-Trustee and the appointing Trustee may not exceed the powers of the
appointing Trustee alone. The Trustee appointing a Co-Trustee may revoke the
appointment at any time,with or without cause.
Section 3.06 Corporate Fiduciaries
Any corporate fiduciary serving under this instrument as a Trustee must be a bank,trust
company,or public charity that is qualified to act as a fiduciary under applicable federal
and state law and that is not related or subordinate to any beneficiary within the meaning
of Internal Revenue Code Section 672(c).
Section 3.07 Incapacity of a Trustee
If any individual Trustee becomes incapacitated, the incapacitated Trustee need not
resign as Trustee. For Trustees other than me,a written declaration of incapacity by the
Co-Trustee or, if none, by the party designated to succeed the incapacitated Trustee,
made in good faith and supported by a written opinion of incapacity by a physician who
has examined the incapacitated Trustee, will terminate the trusteeship. If the Trustee
designated in the written declaration refuses to sign the necessary medical releases
needed to obtain the physician's written opinion of incapacity within 10 days, the
trusteeship will be terminated.
Section 3.08 Appointment of Independent Special Trustee
If for any reason the Trustee of any trust created under this instrument is unwilling or
unable to act with respect to any trust p:operty or any provision of this instrument, the
3-3
Trustee shall appoint, in writing, a corporate fiduciary or an individual to serve as an
Independent Special Trustee as to this property or with respect to this provision. The
Independent Special Trustee appointed may not be related or subordinate to any trust
beneficiary within the meaning of Internal Revenue Code Section 672(c).
An Independent Special Trustee will exercise all fiduciary powers granted by this trust
unless expressly limited elsewhere in this instrument or by the Trustee in the instrument
appointing the Independent Special Trustee. An Independent Special Trustee may resign
at any time by delivering written notice of resignation to the Trustee. Notice of
resignation will be effective in accordance with the terms of the notice.
Section 3.09 Rights and Obligations of Successor Trustees
Each successor Trustee serving under this instrument, whether corporate or individual,
will have all of the title, rights, powers, and privileges granted to the initial Trustee
named under this instrument. In addition,each successor Trustee will be subject to all of
the restrictions imposed upon, as well as to all discretionary and ministerial obligations
and duties given to the initial Trustee named under this instrument.
3-4
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