8 Cushing Street ROD Fee CKV of Sakm Depairtme-nt of Na r ncng and Canrmiuntty Dsvdaprmlem
Ch-cck ece[pt and Trackrh a Form
Please complete the form and make two (2) copies
Date Received �
Q `/o3Ixoxq-
Amount Received �pS,04
Form of Payment D(Check 0 Money Order
Client Information Q C USL erg
U Arts& Culture land Use Boards
0 Artists' Row Rent 0 Planning Board Application Fee
0 Charlotte Forten Plaza Use Fee ® SRA/DRB Fee
Payment received for 0 Derby Square Plaza Use Fee IN ZBA Fee
® Old Town Hall Rental Fee 0 Peer Review Fee
what service? 0 Security Deposit for Escrow Acct. 0 Conservation Commission Fee
Other
0 Salem Ferry
0 Other
Staff receiving payment [3r@Yt 610 PQ VI6h
Additional Notes Pei,,5 Ir`/ a F Deeds Fee {o Re Cori Ae WJ� , h
NAME �1l(-d ` e-- MagAO
ACCOUNT NO. .0 0 4 9�'7'406I 53-179/
DATE 9999999
PAY TO THE Sou 1 flu-► \ ass,Cx ep-5�yv o D� � IQ ,DO
ORDER OF
0O//0 [ DOLLARS
Eastern Bank,
! 1-800-EASTERN/easternbank.com
MEMO (dSh1Yl .j St '5b�A3 �_
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1:0 L L 30 L 7981: 4048 2906 Li'' 9999
� Original Check and Form:Treasurer's Office --
Copy! 1: Client
Copy 2:Application File
LScan and email if required