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266 Canal Street Clerk's 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 q Form of Payment 19 Check ❑ Money Order Client Information 6 troo Arts& Culture land Use Boards ❑ Artists' Row Rent ❑ Planning Board Application Fee ❑ Charlotte Forten Plaza Use Fee ❑ SRA/DRB Fee ❑ Derby Square Plaza Use Fee 0 ZBA Fee Payment received for ❑ 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 g(eYArAn P05tt(A, Additional Notes �_G b �gio%I �+re c 4-- .�. L erK'5 THE FACE OF THIS DOCUMENT HAS A COLORED BACKGROUND ON WHITE PAPER � Beverly Crossing, LLC Norm snore sank S38 15 Rantoul St Beverly, MA 01915 5s��Zsi2�ta ,) u DATE: May 29, 2025 �I ' . i 0©` * ** **105.00 ONLY Rh PAY One Hundred Five and 00/100 Dollars 8 To THE CITY OF SALEM j ORDER 1 OF SALEM, MA 01970 1 THE BACK OF THIS DOCUMENT CONTAINS AN ARTIFICIAL WATERMARK-HOLD AT AN ANGLE TO VIEW 11000063130 1: 2 L L 3 ? L 2981:99L,6 L L980 Original Check and Form: Treasurer's Office Copy 1: Client Copy 2: Application File Scan and email if required