11 Felt 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 Q103 f;
Amount Received
Form of Payment Check ❑ Money Order
Client Information R V` 54mac
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 g�C� ►ol� Pc���G ,
Additional Notes
North Shore Bank 2103
Tinti&NavinS,PC 63-7129/2113
Salem Operating
27 Congress St,Suite 414
Satem,MA 01970
m
0
1' One hundred fifty and NO/100 DATE AMOUNT 0
0
TO THE
ORDER OF :`. 09/30/2025 $150.00
City of Salem
City of Salem
o
AUTHORIZED SIGNATURE�� � RP is
0
voo2i3OP' 1: 2 1 13 7 L 2 981: 99S13973111
Original Check:Treasurer's Office
Copy:Application File
Scan and email if required