284 Washington Street 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 �n
Amount Received to 6",0 0
Form of Payment E� Check ❑ Money Order
Client Information ).,,f) t-[ jv-jr k Ip5ji r �firCe 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 9 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 �rCV V)Sn pc, f)U,,
Additional Notes
6 L-[ VO5 k t1.6 fo0 5+rec+ R0 0 Pee
rinti&Navins,PC North Shore Bank 2079
Salem Operating 69-7129I2113
27 C0119ress St,Suite 414
Salem.MA 01970
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PAY One hundred five and NO/100 m
TO THE DATE AMOUNT
ORDER OF Commonwealth of Massachusetts 09/05/2025 $105.00 a
Commonwealth of Massachusetts
Essex South District Registry of Deeds
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AUTHORIZED SIGNATURE ffi
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11'00207911' 1: 21137L2981: 99SL39 ins I
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required