18 Sutton Avenue 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
Amount Received .po
Form of Payment Check ❑ Money Order
Client Information L,� S to { �(� AvcwAe
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 ® ZBA Fee
❑ Old Town Hall Rental Fee El Peer Review Fee
what service? ❑ Security Deposit for Escrow Acct. ❑ Conservation Commission Fee
Other
❑ Salem Ferry
❑ Other
Staff receiving payment Poy�;Gh
Additional Notes
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JONATHAN c MAGNUSON 10-08 164
28 BLAKELEY ST 57-1l115 RI
LYNN,MA 01905-1830 �/ 53000
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Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required