290 Canal Street ROD 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
Amount Received �p S
Form of Payment IN Check ❑ Money Order
Client Information 1Aa 64lIf t -5tf-3e �
Arts& Culture Land Use Boards
- ❑ Artists' Row Rent ❑ Planning Board Application Fee
❑ Charlotte Forten Plaza Use Fee ❑ SRA/DRB Fee
❑ Derby Square Plaza Use Fee ® ZBA Fee
Payment received for ❑ 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 �2 P96'1 'h
Additional Notes
K C f�Wlar- eca S-io R(5 G4fJ i r9 O C n e6zSfor
Chris&Beth Koeplin 4661
23 Turtle Back Rd
Essex,MA 01929
20Z
PAY TO THE S $ 69 5—r
ORDER OF
}.L DOLLARS
Bank of America
17 Enon Street
Beverly,MA 01915
FOR 7110 CIML -
1:0 11000 L 381: 009 S L 19000 S 20466 L
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required