311-313 Bridge Street 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 Q
Amount Received (r?; .00
Form of Payment Check ❑ Money Order
Client Information ?� ( ( $��d9C Free
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 ❑ 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 grenIla" P05NI-ill
Additional Notes
Ere- c F— Roppee
North Shore Bank 205j2
Tinti&Navins,PC ss-712912113
Salem Operating
27 Congress St.Suite 414
Salem,MA 01970
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PAY One hundred five and NO/100
TO THE DATE AMOUNT `�
ORDER OF Commonwealth of Massachusetts 07/28/2025 $105.00 a
Commonwealth of Massachusetts
Essex South District Registry of DeedsJ,
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n'0020S'211■ 1: 211`371 29Eli: 995 a 3973111
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2:Application File
Scan and email if required