10 Ropes 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
Amount Received 4igc��oa
Form of Payment 21 Check ❑ Money Order
Client Information 16 tams 5 Prvcf
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 EN 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 LOW W CS Sf re+
Additional Notes
14(L fC5 S1-feet —RoDFee
2130
North Shore Bank
sa-r+zslz++s
Tinti&Navins,PC
Salem Operating
27 Congress St,Suite 414
Salem,MA 01970 ID
a
m
cn
v� AMOUNT DATE
PAY
-
TO THE
ORDER OF �� _74-
.....»m,«..,w.r..a.,m AUT14CJPIZ[[7$kiF:Al'Jlie
C
11s002L30e' 37 >, 2931: 99SL397311'
original Check:Treasurer's Office
Copy: Application File
Scan and email if required