124 Boston Street Clerk's Fee City of Salem Department of Planning and Community Development
Check Receipt and Tracking Form
Please complete the form and make one (1) copy
1 Date Received �V O /-hq
1 Amount Received g 1,cL o
Form of Payment 1 Check ❑ Money Order
Client Information g oti kOrl 5 (e C 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 ] 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 B rer ridiri Poi f14/k
Additional Notes
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Tinti&Navins,PC North Shore Bank (�
Salem Operating 63-712912113 2090
27 Congress St.Suite 414
Salem,Iv1A 01970
PAY Two and NO/100
TO THE c
ORDER OF City of Salem DATE. AMOUNT
$2.00
City of Salem 09/16/2025 d
93 Washington Street
Salem,MA 01970
m
11'00 20 90 1: 21 13 ? i 2984
995 � 39 ? 311s
I
Original Check: Treasurer's Office
Copy: Application File
Scan and email if required