55 Butler Street U2 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 0 45
Amount Received i�5 pr
Form of Payment Jgl Check ❑ Money Order
Client Information 55 gvIier St U2—
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 U 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 !J2 reollar) P05.1 't
Additional Notes
�S 5u Iler 5f Uz- RoD Pee
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North Shore Bank 2072
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Salem Operating
27 Congivss St,Suite 414
Salem,MA 01970
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PAY One hundred five and NO/100 AMOUNT
TO THE S
ORDER OF Commonwealth of Massachusetts 08/18/2025 $105.00 d
Commonwealth of Massachusetts _
Essex South District Registry of Deeds
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v00207211n 1: 21L37L29131: 9951397Pe
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2:Application File
Scan and email if required