284 Washington Street 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 �1 w,
Amount Received < ® —
Form of Payment Check ❑ Money Order
Client Information L( � n9 o S+ree f
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 f" 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 B f-coy orn
Additional Notes
Tinti&Navins,PC North Shore Bank 2080
53-712912113
Salem Operating
27 Congress St,Suite 414
Salem,MA 01970
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PAY Two and NO/100 W
DATE AMOUNT w
0
TO THE c
ORDER OF City of Salem 09/05/2025 $2.00 a
City of Salem
93 Washington Street
Salem,MA 01970
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0
AUTFM Z'O SIGNATURE
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0•00 20800 is 2 L L 3 7 1 2 98j: 9 9 S L 3 9 7 P
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required