55 Butler Street U2 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
Form of Payment X1 Check ❑ Money Order
Client Information 5 5 � k W 5 t U1
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 1P 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 red
Additional Notes
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Tinti&Navins,PC North3Sho2113
e Bank 207
Salem Operating
27 Congress St,Suite 414
Salem,MA 01970
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PAY Two hundred fifty and NO/100 DATE AMOUNT
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TO THE o
ORDER OF City of Salem 08/18/2025 $250.00 a
City of Salem
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11800 207 Lill 1: 2 1 137 1 29811: 9 9 S 13973n�
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2:Application File
Scan and email if required