20 Williams 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 O C
Form of Payment Check ❑ Money Order
Client Information
S 5
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
Rr
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 , rO r 4
Additional Notes
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LYNN J.
McMURRY 2118
MCMURRY 12 2Q2
THOMAS J. DATE -�.._-��• .•-.. -„�
20 WILUAMS STREET
SALEM,MA 01970
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PAY O 5-0 DOLLARS 4—Irtk
THE ORDER OF n• 6
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VWIcoo C.HIES R WINCHEMR.MA01890 f•-.-w. /�
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BANK
MEMOT I' �, 2 u� 5 6 7 7
13715731: 01320 38 —
LOOK'OF'FNAUDAETENNING FEATURES INCLUDING THE SECURITY SOUAPE AND NEAT-BFACTIVE INK.DETAILS ON SACK.
Original Check:Treasurer's Office
Copy: Application File
Scan and email if required