22 Prescott Street 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 0 6 ��-/,�07,1;
Amount Received lms,ao
Form of Payment 1'Check ❑ Money Order
Client Information `2 1,- -ffee�
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 [a ZBA 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 Drr)r)6r1 pas f i ch
Additional Notes
PC2yc,ak�- 5�ceg�-
PARID&MIKAELA LLC 53-7055/2113 1064
MA / ?
DATE
T CAP
THE
$ p�,
THE ORDER OF
DOLLARS
a Ink
SalemFfve'®
MEMO „-
AV
1: 2iL37055 LOOOL6 64 837n' 1064 -Mv-- u
LOOK FOR FRAUD-DETERRING FEATURES INCLUDING THE SECURITY SQUARE AND HEAT-REACTIVE INK.DETAILS ON BACK,
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required