116 Highland Avenue Unit A1 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
Amount Received 10 5.o Q
Form of Payment [Check ❑ Money Order
Client Information [ (b �( ,Jk tend Avenue Un if .
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 lY 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 P{e el PoSt;%!7
Additional Notes
� ( 6 p['Jintorj Avenue Ur)P AZ-RoOFOO
North Shore Bank 2086
Tinti&Navins,PC 63-1129/2113
Salem Operating
27 Congress St,Suite 414
Salem.MA 01970
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0
0
PAY One hundred five and NO/100 DarE AMOUNT
TO THE °
ORDER OF Commonwealth of Massachusetts 09/08/2025 $105.00 a
Commonwealth of Massachusetts
Essex South District Registry of Deeds
m
AUTHORIZED SIGNATURE
11100208Go 1: 21L37i2984 - 995i3973119 I
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2:Application File
Scan and email if required