8 Cushing Street Clerk's Fee 1
CCKV ®f Sflam Departr-n-ent of P1,to nft and Camim, n- ty Dsve ®porrnem
Check °eceopt and Track[n Q F cc) rm
Please complete the form and make two (2) copies
Date Received Q q10 3)IS,
Amount Received cl;� , Qo
Form of Payment Y Check El Money Order
Client Information $ Lu +fee " Z8h
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 .W ZBA Fee
® Old Town Hall Rental Fee ® Peer Review Fee
what service? ® Security Deposit for Escrow Acct. 10 Conservation Commission Fee
Other
® Salem Ferry
® Other
Staff receiving payment Brertid{) POS+%C I,
Additional (Votes Gtenc'5 Pee {o S�orplke DeCfw ar
NAME Co(���y~ D �l 1, Q�t/n� 53 1�I t
113
ACCOUNT NO. O 1 — — 9
DATE 999
PAY TO THE O
ORDER OF ✓ m $ a 00
0
a t'� C�` /t O U t DOLLARS �"�.:�.....
Eastern Bank
1-800-EASTERN/easternbank.com
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1:0 L L 30 L ?981: 4048 2906 L0 9999
Original Check and Form:Treasurer's Office
Copy 1: Client
Copy 2:Application File r
Scan and email If required