8 Woodbury Court 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 5 (p 5 .o0
Form of Payment ® Check ❑ Money Order
Client Information W0036VO tavr-+
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 gC�nnan F05ft61,
Additional Notes
A waoj ti Ltry co u r K0 D Pee
CLAUDIA PARASCHIV
22 FOWLER ST0
s' SALEM MA 01970
53-8411/2113
Pay to the S Dates CHECK ARNgR
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i Lynn,MassXhLwm 01904
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1
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required