43 Rear Walter 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
Amount Received a
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Form of Payment ItMheck ❑ Money Order
Client Information �1616S
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 -r'q t
Additional Notes ,
WoORWS BY JESSE DEBENEDICTIS LLC '-Zi2,o
GLOUCE OO R,MA 019303347 837
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Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required