16 Eden 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 -7
Amount Received $JWQ
Form of Payment [Sr Check ❑ Money Order
Client Information 16 fden S�ree�-- AY5e) �1 tw'1azKulaS
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 Il 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 g rennan pc,/74-.�h
Additional Notes
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97 Central St Apt 2 "-131.10"A '
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Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required