6 Botts Court 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 WoD <4 Q
Form of Payment ,Check ❑ Money Order
Client Information C k(i5 D rVay > G k k5 Co vr�
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. Fee
Other
❑ Salem Ferry
❑ Other
Staff receiving payment grtorte P61;a-)
Additional Notes
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CHRIS DRUCAS ATTORNEY AT LAW -70ss/z1 13 2300
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Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required