86 Highland Avenue ROD Fee City of Salem Department of Planning and Community Development
Check Receipt and Tracking Form
Please complete the form and make two (2) copies
Date Received
Amount Received a
Form of Payment Check ❑ Money Order
Client Information
Arts& Culture Land Use Boards
❑ Artists' Row Rent ❑ Planning Board Application Fee
❑ Charlotte Forten Plaza Use Fee ❑ SRA/DRB Fee
Payment received for ❑ Derby Square Plaza Use Fee EYZBA Fee
❑ Old Town Hall Rental Fee ❑ Peer Review Fee
what service? ❑ Security Deposit for Escrow Acct. ❑ Conservation Commission Fee
Other
❑ Salem Ferry
❑ Other
Staff receiving payment LA��
Additional Notes , L�o,n
North Shore Bank 1975
Tinti&Navins,PC 53-7129/2113
Salem Operating
27 Congress St,Suite 414
Salem,MA 01970
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PAY One hundred five and NO/100 DATE AMOUNT `0
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TO THE o
ORDER OF Commonwealth of Massachusetts 04/10/2025 $105.00 a
Commonwealth of Massachusetts
Essex South District Registry of Deeds
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v00197Se 1: 21137 2981: 99S 1397311■
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required