124 Boston Street ZBA 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 Oct l [
Amount Received �y�5�1. oo
Form of Payment 10 Check ❑ Money Order
Client Information �064Grl � �ree�
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 21 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 �,�e f) b
Additional Notes
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North Shore Bank 2088
Ti tit i &Navins,PC 53-7129/2113
Salem Operating
27 Congress St,Suite 4 t 4
Salem,MA 01970
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PAY Two hundred fifty and NO/100 DATE AMOUNT c
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TO THE
ORDER OF City of Salem 09/16/2025 $250.00 a
City of Salem
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AVTHORIZED S*NATURE
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n'002088u' 1: 2113712g81: q q S 3g73u'
Original Check: Treasurer's Office
Copy: Application File
Scan and email if required