311-313 Bridge Street 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
Amount Received �y 0 ,,U p
Form of Payment -0 Check ❑ Money Order
Client Information 9C .,*(as
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 �J ZBA Fee
what service? ❑ Old Town Hall Rental Fee ❑ Peer Review Fee
❑ Security Deposit for Escrow Acct. ❑ Conservation Commission Fee
Other
❑ Salem Ferry
❑ Other
Staff receiving payment R ran nar, poh f; 6+
Additional Notes
r North Shore Sank 2051
Tinti&Navins,PC w.ii2ehii3
Salem Operating
27 Congress St,Suite 414
Salem,MA 01970
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PAY Two hundred fifty and NO/100 DATE AMOUNT `0
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TO THE &
ORDER OF City of Salem 07/28/2025 $250.00 a
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City of Salem
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0020S 1: 2 3 ,r 29131: 99S1397311'
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2:Application File
Scan and email if required