22 Vista Avenue 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 ��QO
Form of Payment 09 Check ❑ Money Order
Client Information ';,X. V,yo A VeVI V C
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 g ZBA 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 g��nnan �QSfi C h
Additional Notes
X,1, V A S AV-ctn U-c-- G i Fee
North Shore Bank 2014
Tint!&Navins,PC 63-712912113
Salem Operating
27 Congress St,Suite 414
Salem,MA 01970
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PAY Two and NO/100 AMOUNT o
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TO THE ORDER OF 05/15/2025 $2.00 a
City of Salem
City of Salem
93 Washington Street
Salem,MA 01970 m
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1120020110's 1: 21137 . 2981: ggS13g73112
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required