3 Lemon 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
Amount Received d/
Form of Payment Check ❑ Money Order
Client Information
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
what service? ❑ Old Town Hall Rental Fee ❑ Peer Review Fee
❑ Security Deposit for Escrow Acct. ❑ Conservation Commission Fee
Other
❑ Salem Ferry
Other
Staff receiving payment
Additional Notes
C k" Lems,-,
BRAYDEN C VARR 97-311/1240
3 LEMON STREET .1068
SALEM,MA 01970
DATE
PAY TO THE
� ORDER
$ O-C)
DOLLARS
" aI'y BANK.
MEMO 3
1: 1 2400 3 1 161.
10 3 299 2 L y 2►►' 1068 .-----�_-------
Original Check and Form: Treasurer's Office t— --- —
Copy 1: Client
Copy 2:Application File
Scan and email if required