3.5 Rear Buffum 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 t, / / ,�0-)-
Amount Received ,Qp
Form of Payment El Check ❑ Money Order
Client Information 3 guPFuri fee¢
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 (4 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 5(e666ri
Additional Notes
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CC CELA CONSTRUCTION LLC 53-179/113 358
44 BUTLER ST.#2
SALEM,MA 01970 DATE .
PAY TO ( l I V P Q 0
THE ORDER OF
DOLLARS
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®E,&Stern Bank .,MA02110
eastembank.com
f 1.800-EASTERN
MEMO C.c'R L A _.._�_ ._.__ .... _ _.W_ .. _ _ ..._� ..._M!
i:0113017981: 06019 269801" 0358
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required