6 Botts Court ZBA 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
47
Amount Received (Sps 0,0
Form of Payment l Check ❑ Money Order
Client Information �s pruca _ g �s (oL r,
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
G bof+5 Gazer Fee
— 17 7 7V, ??Y � .— �-.�;
53-7055/2113 2299
CHRIS DRUCAS ATTORNEY AT LAW
CLIENT'S FUND ACCOUNT
DATE
PAY TO THE
w ORDER OF___ $ I
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a SalemFi*�' IF�
ve ,
1: 2 1 1 3 70 5 58i: OB 9 900 5 90 411'
2 299
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required