55 Butler Street U2 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 i l ' 0 0
Form of Payment Check ❑ Money Order
Client Information SS 41Or-
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 0 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 �f'Cr
Additional Notes
S U,fIcr U C0,5 Fee
North Shore Bank 2073
Tinti&Navins,PC 63.712912113
Salem Operating
27 Congress St,Suite 414
Salem,MA 01970
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PAY Two and NO/100 DATE AMOUNT
TO THE
ORDER OF City of Salem 08/18/2025 $2.00
City of Salem
93 Washington Street � (�
Salem,MA 01970
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AUTHOR VED SGNATURE
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v002073u+ 1: 21L3712g8l: ggSd3g73111 I
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2:Application File
Scan and email if required