34 Boston Street Clerk and Registration Fee City of Salem Department of Planning and Community Development
Check Receipt and Tracking Form
Please complete the form and make two (2) copies
Date Receive
Amount Received a O 0
Form of Payment ❑ Check ❑ Money Order
Client Information /11Aard
17 AA&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 XZBA Fee
❑ Old Town Hall Rental Fee ❑ Peer Review Fee
what service? ❑ Security Deposit for Escrow Acct. ❑ Conservation Commission Fee
Other
❑ Salem Ferry
❑ Other
Staff receiving payment �,` ro r r„e 544.E
Additional dotes
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C.Gonzalez
Alnardy Date
18 Sunny Ave
o1844-5909 a
Methuen MA t?
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Pay to the --- — - — Dollars 8
order of �- H
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mFive
Sale
SIGNED
MEMO_ -- 0 0
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,� 2LL37558 �: L00021 8III2L11311100
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Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2:Application File
Scan and email if required
City of Salem Department of Planning and Community Development
Check Receipt and Tracking Form
Please complete the form and make two (Z) copies
Date Received Od- /4/ ay
Amount Received c�1� /65 , p p —
Form of Payment ❑ Check ❑ Money Order
Client Information 41 A A
twil
Arfs& 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
Old Town Hall Rental Fee Peer Review Fee
what service? ❑ Security Deposit for Escrow Acct. ❑ Conservation Commission Fee
Other
❑ Salem Ferry
❑ Other
Staff receiving payment Ira rr.1-,Cd'1CJ
Additional Notes
30 505h9n .,�fr
Ainardy C. Gonzalez 89
18 Sunny Ave f`9 I 3_ 53-7055/2113
Methuen MA 01844-5909 Date v—
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SalemFi e
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MEMO SIGNED_ m
l: 2 L L 3 70 S SBi: L000 2 12 2 L LBOD089
Original Check and Form:Treasurer's Office
Copy 1: Client
Copy Z:Application File
Scan and email if required