290 Canal Street Clerk's 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 Received 41 Lt J a(3?r Jf
Amount Received-•ap
Form of Payment 19 Check ❑ Money Order
Client Information q4 f�nAl 5;leek
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 0 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 (-ex*,-am
Additional Notes
Chris&Beth Koeplin
23 Turtle Back Rd 4662
Essex,MA 01929
PAY TO THE
ORDER OF
�v
Bank of America 5...„n
17 Enon Street DOLLARS
Beverly,MA 01915
FOR
,:0 11000 1 38,: 00 9 S L 19000 S 211■
466 2
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required