22 Vista Avenue ZBA 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 O 5 f r 9 I'�o). 57
Amount Received ( �0-CIO
Form of Payment Vq Check ❑ Money Order
Client Information ',i+a Avenge
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 IN 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 5(enndtl Po,flcl
Additional Notes
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North Shore Bank 2012
Tinti&Navins,PC 5 3-71 291211 3
Salem Operating
27 Congress St,Suite 414
Salem,MA 01970
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PAY One hundred fifty and NO/100 DATE AMOUNT e
TO THE o
ORDER OF City of Salem 05/15/2025 $150.00 a
City of Salem
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AUTHORIZED SIGNATURE �• •w� p a
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111002012v 42113712984 995 3q Pe I
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required