116 Highland Avenue Unit A1 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 9 1 1 S/
Amount Received
Form of Payment Check ❑ Money Order
Client Information l [ 6 )4 ,5 lard /fiver ue Un 4A1
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 C' 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 �,r��V1,Atj Po ti ¢,G(,
Additional Notes
� j 6 p, 91 d0j Aver UC Dr, 11 7 8A Fee
North Shore Bank
2084
Tinti&Navins,PC 5
3-71 Z9/2113
Salem Operating
27 Congress St,Suite 414
Salem,MA 01970 $
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0
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DATE AMOUNT o
PAY Two hundred fifty and NO/100 z
TO THE 09/08/2025 $250.00 a
ORDER OF City of Salem
City of Salem
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AUTHORIZED SfGNATURE ... Ar G
11■00 2084u' 1: 2 L 13 7 L 2981: 99 S L 39 7 3115
7. a;nriK ana corm: Treasurer's Office
Copy 1: Client
Copy 2:Application File
Scan and email if required