3.5 Rear Buffum 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 Ll / 7,�, / 0 y-
Amount Received �� pd
Form of Payment Check ❑ Money Order
Client Information 3 FUm
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 D( 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 ► (W100 PO Stl f k
Additional Notes
CC CELA CONSTRUCTION LLC 53-179/113 359
44 BUTLER ST.#2
SALEM,MA 01970 DATE
PAY To R e j e OrY a;- Peed t _i $
THE ORDER O1F n
ONO L,I iI f 1-.0 OIIff_ Y� DOLLARS
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eaetembank.com
1�00-EASTERN Ar
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1:0 L 130 l 7981: 060 19 26980ii' 0 3 59
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required