43 Rear Walter 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
Amount Received v r �l
Form of Payment M Check ❑ Money Order
Client InformationVWLA
A s& 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 Al 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 1'
Additional Notes
WORKS BY JESSE DEBENEDICTIS LLC '-2/270
10 LYNWOOD AVE 838
GLOUCESTER.MA 019303341 Q 0
DAiE b iJY 1Q`�
PAY TO THE
ORDER OF
r JG ✓U
CHASE CF DOLLARS 8
JPMorgan Chase Bank,N.A.
www chase.00rn,
MEMO
800 180 38 79 3008 38
Original Check and Form: Treasurer's Office
Copy 1: Client
Copy 2: Application File
Scan and email if required