3 Lemon Street Application 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 j-G�Gc
Form of Payment Lid Check ❑ Money Order
Client Information
Arts& Cultur 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 TKZBA 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 � -44, 6,- r r e-
Additional (Votes
cum - 2786
MS MASONRY &STONE SERVICES INC. 3343/110
9 mAPLE RD 21030
SAUGUS,MA olW6-2432 ('�S
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PAY
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BANK OF AMERICA--�I
FOR PAY � �- � 3 1�-' � _—-
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DO 2 7611' 1:0 11000 1 38,: 001+64 SF 284 ����
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required