801 Payment to Agency Report (Lazy Dog Restaurant) 03-11-24Payment to Agency Report A Public D
1. Agency Name
City of Cupertino
Division, Department, or Region (if applicable)
City Manager
Street Address
10300 Torre Ave., Cupertino CA 95014
Area Code/Phone Number Email
408-777-3225 kirstens@cupertino.org
Agency Contact (name and title)
Kirsten Squarcia, City Clerk
2. Donor Name and Address
LE_� v E
Date Stamp
M AR 1 1 2024
CUP R71N0 CITY CLE
TO AGENCY REPORT
Official Use Only
❑ Amendment (explain in comment section)
Date of Original Filing:
(month, day, year)
❑ Individual ® Other Lazy Dog Restaurant & Bar
Last Name First Name Name
Cupertino CA 95014
Address City State Zip Code
Restaurant business that prepares and serves food and drinks onsite and takeout.
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:
$ 500.00 $
Name Amount Name Amount
3. Payment Information (Complete Sections 3.1 (a or b), 3.2, 3.3)
3.1 (a) Travel Payment
Location of Travel Dates (month, day, year)
❑ Rail ❑ Air ❑ Bus ❑ Auto ❑ Other
Transportation Provider Check Applicable Boxes Name of Lodging Facility
$ Lodging Expenses $ Meal Expenses Transportation Expenses $ Other Expenses $ Total Expenses
3.1 (b) Payment(s) 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.
Food donation for all attendees of the Cupertino Swearing -in -Ceremony held on 2/15/24.
3.3. Identify the officials who used the payment in Section 3.1 (See instructions)
Last Name First Name
Last Name
4. Verification
I authori4�dt accepta
First Name
Position/Title
Position/Title
the reported payment(s) as in compliance with FPPC regulations.
Pamela Wu City Manager
Print Name Title
Department/Division
Department/Division
03/ 11 /24
(month, day, year)
(Use this space or an attachment for any additional information)
FPPC Form 801 (Jan/18)
advice@fppc.ca.gov