124 Boston Street ROD Fee City of Salem Department of Planning and Community Development
Check Receipt and Tracking Form
Please complete the form and make one (1) copy
Date Received
Amount Received [A 9 v
Form of Payment 9 Check ❑ Money Order
Client Information ��l v� q►-, C� � ,�,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 M 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 gce r1rian F05 H1 Gk
Additional Notes
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North Shore Bank 2089
Tinti&Navins,PC 63-7129/2113
Salem Operating
27 Congress St.Suite 414
Salem,MA 01970
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PAY One hundred five and NO/100 DATE AMOUNT
0
TO THE
ORDER OF Commonwealth of Massachusetts 09/16/2025 $105.00 a
Commonwealth of Massachusetts
Essex South District Registry of Deeds 7
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Original Check: Treasurer's Office
Copy: Application File
Scan and email if required