3.5 Rear Buffum Street Application 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 * W)L_
Amount Received $ 150. Q 0
Form of Payment Check ❑ Money Order
Client Information 3/,�. R gu FFun S�ree4
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 IN 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)f 8 n rdn P GI 4 iCH
Additional Notes
A),, R g uppu n S t rm f - Z V MPl)w;an Fee
CC CELA CONSTRUCTION LLC 53-179/113 357
44 BUTLER ST.#2 SALEM,MA 01970 DATE Q!n`.Z— Z -3'1
PAY TO f [['� C I
THE
^ORDER OF� Anfwm
F)OLLAARSVLJ ww.
®Fast`+&iMk Burton,MA 02110
eastembank.com
1.800-EASTERN
MEMO l
1:0 1130 17981: 060 L9 26980iin 0357
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required