30 Leavitt Street ROD Fee City of Salem Department of Planning and Community Development
Check Receipt and Tracking Form
Please complete the form and make one (1) copy
Date Received 716-
Amount Received to5100
Form of Payment 0 Check ❑ Money Order
Client Information 30
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 W 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
30- Leav ++ 5fr'ee� — Rop Fee
Derby Square Architects, Inc. East 2480
265 FRANKLIN ST NKLIN
11 Derby Square, Unit 4 BOST05_M9 0131 0-311 3
Salem, MA 01970
978-740-9979
a
0
PAY One Hundred Five and no/100
a
DATE CHECK CHECKAMOLINT
10/09/25 2480 $105.00
TO THE
50U tiro FySex Rc,9;, 7ol WaJ5 — 13P
ORDER
OF 98 WASHINGTON ST m
CITY HALL ANNEX, 2ND FLOOR
SALEM MA 01970
IZED SIGNATURE
11000 2480,11 1:0 L 130 L 7981: 060 138 2 2 S Sill
Original Check: Treasurer's Office
Copy: Application File
Scan and email if required