84-86 Derby Street Clerk's Fee Chem ftce[V and TracWh a roam
Please complete the forma and make two (2) copies
Date Received 0
Amount Received 47 . a0
Form of Payment V Check ❑ Money Order
Client Information � G DC(V-f 5�8'eef
Arts& Culture Land Use Boards;
® Artists' Row Rent ❑ Planning pp Board Application Fee
❑ Charlotte Forten Plaza Use Fee ❑ SRA/DRB Fee
Payment received for ❑ Derby Square Plaza Use Fee 19 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 (3 ��0r1Dct� egyfiu.
Additional Notes z,ao r,Le{x`5 Fee
2082
MAITLAND FARM LLC
23 CEDARCREST AVE
SALEM,MA 01970
� _ y DATE L7/.- 53-7055/2113
PAY
TO THE
ORDER OF _ � �
DOLLARS 8
S er e f
FOR LL
11200 208 2110 1: 2 L 13 70 5 SW: 1000 2 30 4 2 ?&in
Original Check and Forma: Treasurer's Office
Copy 1: Client
Copy 2:Application File
Scan and email if required