22 Prescott 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 Q 6 f Z s i
Amount Received 4 )_.00
Form of Payment Eff Check ❑ Money Order
Client Information �j f$b6&j tQ,e p(e6W,p %fee+
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 M ZBA Fee
what service? ❑ Old Town Hall Rental Fee ❑ Peer Review Fee
❑ Security Deposit for Escrow Acct. ❑ Conservation Commission gee
Other
❑ Salem Ferry
❑ Other
Staff receiving payment grennan Pa GI•,
Additional Notes
53-7055/2113 1065
PARID&MIKAELA LLC
MA DATE
PAY TO
THE ORDER OF
DOLLARS �n�echve
Sally
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MEMO A 1
1: 2 13705 �: L000 L686 L065
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