801 Payment to Agency Report (City of Cupertino IS and Public Works) 02-15-17 Payment to Agency Report A Public Docu ,nt— ------PMMSfv TO AGENCY REPORT
1. Agency Name D I laatta p
City of Cupertino • '
Division, Department,or Region(if applicable) Official Use Only
FEB 1 2017
Street Address
10300 Torre Ave, Cupertino, CA 95014 Cl CPC JTIl�O CITY CL RK
Area Code/Phone Number Email
❑ Amendment(explain in comment section)
408-777-3200 manager @cupertino.org
Agency Contact(name and title) Date of Original Filing:
(month,day,year)
David Brandt, City Manager
2. Donor Name and Address
F1 Individual ❑✓ Other
Google Inc
Address City State Zip Code
If"Other"is marked,describe the entity's business activity(if business)or its nature and interests.
� 0 If applicable, identify the name of each source and the amount(s)received by the donor for this payment:
Name $ Amount Name $ Amount
3. Payment Information (Complete Sections 3.1 (a or b), 3.2, 3.3)
3.1 (a)Travel Payment Washington D.C. 4/11/16-4/14/16
Location of Travel Dates(month,day,year)
Virgin America Rail ✓ Air Washington Hilton
❑ ❑ ❑Bus ❑Auto ❑Other
Transportation Provider Check Applicable Boxes Name of Lodging Facility
$ 1,600.00 $528.00 $1,052.12 $ $3,180.12
Lodging Expenses Meal Expenses Transportation Expenses Other Expenses Total Expenses
3.1 (b) Payments) not related to travel: $
Dates(month,day,year) Total Expenses
3.2. Payment Description. Provide a specific description of the payment and its agency purpose and use.
Travel expenses to participate in Waze Connected Citizens Partner Summit April 12-13.
3.3. Identify the officials who used the payment in Section 3.1 (see instructions)
Johnson Jo Anne Senior Engineering Tech Public Works
Last Name First Name Position/Title De partment/D!vision
Gerhardt Teri GIS Coordinator IS
Last Name First Name Position/Title Department/Division
4. Verification
I..a7 or ed the acc ptance of the repo d pent(s) as in compliance with FPPC regulations.
107-� t
�— Signature Print Name Title (month,day,year)
Comment:
(Use this space or an attachment for any additional information)
FPPC Form 801 (Jan/14)
advice @fppc.ca.gov