8 Woodbury Court ZBA 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 0 5
Amount Received 50.00
Form of Payment IN Check ❑ Money Order
Client Information wand bvey Lopr4
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 �(-d n n dlh FWI C�
Additional Notes
1 raai6 ur`/ Go ujO — Z &,A Fee
CLAUDIA PARASCHIV 152
{ 22 FOWLER ST 53-841112113
SALEM MA 01970 S/2� Zo2
�T-� LlatR. CHECK 111M9R I
Pa to the
Order of C 1 jY er���� 150
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CREDIT UNION
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Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required