311-313 Bridge 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 0 r
Amount Received �,op
Form of Payment [�(Check ❑ Money Order
Client Information alr 11 e �
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 15 ZBA Fee
El 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 fen I1do QQ
Additional Notes
North Shore Bank 2053
Tinti&Navins,PC 53-7129/2113
Salem Operating
27 Congress St,Suite 414
Salem,MA 01970
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0
PAY Two and NO/100 DATE AMOUNT
TO THE O
ORDER OF City of Salem 07/28/2025 $2.00 4
City of Salem
93 Washington Street
Salem,MA 01970
O
AUTF;RIZED SIGNATURE r
1120020SAr 1: 21L3712981: 99SL397311, I
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required