284 Washington Street 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 Z 60.0a
Form of Payment ff Check ❑ Money Order
Client Information
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 ® 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
Additional Notes
Tinti&Navins,PC North Shore Bank 2078
Salem Operating 63-7729/2113
27 Congress St,Suite 414
Salem,MA O1970
S
0
PAY Two hundred fifty and NO/100 W
TO THE DATE N
ORDER OF City Of Salem
y 09/05/2025 $250.00 a
City of Salem
0
t
.2AUTHOAM SIGNATURE11■0020Me 1: 2LL3 ? L2981: 99SL39 I
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2:Application File
Scan and email if required