10 Ropes Street Clerk's 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 l(l �pz 1�
Amount Received Z,ao
Form of Payment 19 Check ❑ Money Order
Client Information 0 Ropes G�ree4
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 grenn(m PoSt�Gh
Additional Notes
�a R�Pes S1-trc -&ierk,,G Fee
North Shore Bank 2131
Tinti&NavinS,PC e3-712912113
Salem Operating
27 Congress St,Suite 414
Salem,MA 01970
PAY / J� D� � DATE AMOUNT
TO THE �C/t/J
ORDER OF
C �
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u'00213L1i' 1: 2LL3712981: 995g3973i1'
Original Check:Treasurer's Office
Copy: Application File
Scan and email if required