11 Felt 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
Form of Payment Check ❑ Money Order
Client Information 5 ffrae�
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 (��et�n p��i� °��•
Additional Notes 1
Fee
Tinti&Navins,PC North Shore Bank 2104
Salem Operating 63-7129/2113
27 Congress St,Suite 414
Salem,MA 01970
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PAY One hundred five and NO/]00
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TO THE DATE AMOUNT
ORDER OF Commonwealth of Massachusetts
09/30/2025 $105.00 a
Commonwealth of Massachusetts
Essex South District Registry of Deeds
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AUfHOR1ZEo SIGNATURE
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11300 2 10 LOIN 1: 2113712981: 3973112
Original Check: Treasurer's Office
Copy: Application File
Scan and email if required