116 Highland Avenue Unit A1 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
Amount Received --
Form of Payment Check ❑ Money Order
Client Information 1 l 6 yt l�,WWJ R Ver UC V rl,'M2
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 0 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 �(�Y1YlA�l Qc�it1 t h
Additional Notes
C[ � H;)H1(J0JAVWX Vr) ('fAI- tlerk'� FCC
Tinti&Navins,PC North Shore Bank 2085
Salem Operating 53-712912113
27 CongresS St.Suite 414
Salem,MA 01970
a
PAY Two and NO/100
To THE DATE
ORDER OF AMOUNT
City of Salem o
09/08/2025 $2.00 0.
City of Salem °
93 Washington Street
Salem,MA 01970
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AUTHORIZEDStGNATUr,
11000 208 Sup 1: 2 1 L 3 7 i 2981: �
995139 ? 3u
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2:Application File
Scan and email if required