84-86 Derby Street ROD Fee CCKV of Sdem Departna—e t of Nannic c and Con-ritmct3cgKy Dave optnen,�
Me—& ° ece[pt and Ti rack[n o Rom
Please complete the form and rake two (2) copies
Date Received a I y 1 to 5 -
Amount Received $ fa S,QO
Form of Payment VrCheck 0 Money Order
Client Information e c-1 Derlt6/ Leff
Arts& Culture Land Use Boards
® Artists' Row Rent 0 Planning Board Application Fee
0 Charlotte Forten Plaza Use Fee 0 SRA/DRB Fee
Payment received for 0 Derby Square Plaza Use Fee ,.® ZBA Fee
what service? 0 Old Town Hall Rental Fee 0 Peer Review Fee
® Security Deposit for Escrow Acct. 0 Conservation Commission Fee
Other
0 Salem Ferry
0 Other
Staff receiving payment r e onoto P i2 5f;Cb
Additional Notes 0S, POp Rr-
I
I
2083
MAITLAND FARM LLC
23 CEDARCREST AVE
SALEM,MA 01970
S 53-7055/2113
DATE_ r
PAY
TOTHE
ORDER OF I $ f o 7
QZv� M11 DOLLARS lA(
- SaletnFfve® .i
FOR
11000 208 3110 1: 2 113 70 5 581: 1000 2 30 4 2 7131"
Original Check and Form:Treasurer's Office — ---- - -_ - --- -
Copy 1:Client
Copy 2:Application File
Scars and email if required