Appendix 1 FIGURE 14. SAMPLE FAA FORM 8130-6, APPLICATION FOR A SPECIAL AIRWORTHINESS CERTIFICATE – SPECIAL FLIGHT PERMIT FOR FERRY FLIGHT IN
EXCESS OF MAXIMUM TAKE-OFF WEIGHT (REVERSE SIDE) (cont’d.)
PRODUCTION CERTIFICATE (Give produc tion c ertifi cate n um ber)
TYPE CE RTIFICA TE ONLY
APPROVED PROD UCTION INSPE CTION SYSTEM A. DESCRIPTION OF AIRCRAFT VIII. AIRWORTH IN ESS
DOCUMENTA TION (FAA/DESIGNEE use only) VI. PRODUCTION
FLIGHT TESTING B. Current Ope rat ing Li mit ati ons At tac hed C. Data, Draw ings , Ph otog raph s, e tc. (Attach when requ ired) D. Current W eig ht a nd B alan ce I nfor mati on A vail able in Airc raft E. M ajor Repa ir a nd A lter atio n, F AA F orm 337 (Attach when requ ired) F. This insp ectio n Rec orded in A ircra ft Re cords A. Operating Limi tati ons and M ark ings in Comp lian ce w ith 14 C FR s ecti on 9 1.9, a s A ppl ica ble H. Foreign Airworthiness Cer tification for Import Ai rcraft (Attac h wh en r equi red) I. Previous A irwor thine ss Ce rtifi cate Issue d in Accor dance with J. Current Airwor thine ss Ce rtifi cate Issue d in Accor dance with G. Statement of Con for mit y, FAA Fo rm 813 0-9 (Attach when requ ired)
SERIAL NUMBER 27- 647 SIGNATUREDATE OF APPLICATION NAME AND TITLE (Print o r type)
NAME ADDRESS A. MANUFACTURER B. PRODUCTION BASIS (Check ap plicabl e item ) B. DESCRIPTION OF FLIGHT FROM El Pas o T exas
DEPARTURE DATE 11/3 0/ 96 TO Maui, Hawaii DATE 11/2 5/ 96 NAME AND TITLE (Print o r type) Don Brow n, A gent
SIGNATURE C. CREW REQUIRED TO OPERATE TH E AIRCRAFT AND ITS EQUIPMENT F. CERTIFICATION - I hereby certify that I am t he r egis tere d ow ner (or his agen t) o f th e ai rcra ft d escr ibed abo ve; that the air craf t is reg iste red with the Fed eral Avi atio n Ad mini stra tion in accordance with Ti tle 49 of th e U nit ed Sta tes Co de 441 01 et seq. and applicable Federal Aviatio n R egu lat ion s; and th at the ai rcr aft ha s b een in spe cte d a nd is air wor thy fo r t he fli ght descr ibed.
VIA San J ose, Calif ornia C. GIVE QUANTITY OF CERTIFICATES R EQUIRED F OR OPERAT ING NEEDS BUILDER (Make) Piper
REGISTERED OW NER Weldon H. Jac kson
REGISTRATION MARK N45 88P MODEL PA 23- 250
ADDRESS P.O. Box 945 , M a ui, Hawa ii 9 6782
DURATION 30 Days D. THE AIRC RAFT DOES NOT MEET THE APPLICABLE AIRW ORTHINE SS REQUIR EMENTS AS FOLLOW S:
Temporary Ferr y Fu el S tste m in stal led in a ccor danc e wi th F AA F orm 337, "M a jor Repa ir a nd A lter atio n" d ated 12/ 88.
Gros s we ight not to exce ed 1 10% of c erti fied max imun wei ght.
E. THE FOLLOW ING RESTR ICTIONS A RE CONSID ERED NECE SSARY FOR SAFE OPE RATION: ( Use atta chm en t if neces sary)
1. W hen the air craf t is in an o verw eigh t co ndit ion, the des ign crui se s peed sho uld not exce ed 162 M PH.
2. The fuel qua nti ty sho uld no t e xce ed 140 ga llo ns in the fo rwa rd tan k a nd 35 gal lon s i n t he aft ta nk.
3. The sequ ence of use of t he f erry tan ks s hall be as s hown by a te mpor ary plac ard inst alle d in ful l vi ew o f th e pi lot.
(Check if a pplicable)CUSTOMER DEMONSTRATION FLIGHTS XP I L O T XC O - P I L O T FLIGHT ENGINEER OTHER (Specify) 14 CFR Section CAR (Origin al Att ached) 14 CFR Section (Copy atta ched) VII. SPECIAL FLIGHT PER MIT PUR POSES OTHER THAN PRODUC TION FLIGHT TEST FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006
Appendix 1 FIGURE 15. SAMPLE FAA FORM 8130-6, APPLICATION FOR A SPECIAL AIRWORTHINESS CERTIFICATE – SPECIAL FLIGHT PERMIT FOR FERRY FLIGHT (FACE SIDE)
APPLICATION FOR
AIRWORTHINESS
CERTIFICATE II . CERTIFICATION REQUESTED EXPERIMEN TAL ONLY (Enter hours flown s ince la st cert ificate CERTIFICATED R EPAIR STATION (Give CertificateCERTIFICATED MECHANIC (Give AIRCRAFT SPECIFICATION O R TYPE CER TIFICATE D ATA SHEET (Give No. and AIRW ORTHINES S DIRECTIVES (Check if all ap plica ble A D's c om pli ed wi th an d giv e the num b er of the last AD SUPP LEM EN T ava ilabl e in the b iweek ly se ries as of the date of ap plica tion)
issued or re newed) N/A No.)
Revision No.)
14 CF R part 121 C ERTIFI CATE H OLDER (Give Certificate No.)
A. REGISTE RED OW NER (A s show n on c ertifi cate o f airc raft r egistr ation) V. FAA
REPRESENTATIVE
CERTIFICATION I. AIRCRAFT DESCRIPTIONIII. OWNER'S CER TIFICATION IV. INSPECTION AGENCY
VERIFICATIO N A B X STANDARD AIRW ORTHINESS CERTIFICATE (Indicate category) SPECIAL AIR W ORTHINESS CERTIFICATE (Check approp riate item s)
1. REGISTR ATION MARK
APPLICAT ION IS H EREBY MA DE FOR: (Check a pplicabl e item s)
2. AIRCRAFT BU ILDER'S NAME (M ake)
FAA CODING3. AIRCRAFT MODEL DESIGNATION
4. YR. M FR.
7. ENGINE MODEL DESIGNATION
10. PRO PELLER MODEL DESIG NATION
IM PORT
11. AIRC RAFT IS (Check if appl icable) DATE DISTRICT OFFICE DESIGNEE'S SIG NATURE AND NO. FAA INSPECTOR 'S SIGNATURE (Check ALL appli cable bloc ks in item s A a nd B) A. I fin d th at t he a ircr aft desc ribe d in Sec tion I o r VI I me ets requ irem ents for
NAME ADDRESS B. AIRCRAFT CERTIFICATION BASIS (C heck appli cable bloc ks an d com plete item s as indic ated) C. AIRCRAFT OPERATION AND MAINTENANCE RECORDS
CHECK IF RECORDS IN
COMPLIANCE WITH 14 CF R se ctio n 91 .417
TOTAL AIRFRAME HOURS 3
DATE OF APPLICATION D. CERTIFICATION - I hereby certify that I am the regi ster ed o wner (or his age nt) of t he a ircr aft desc ribe d ab ove, tha t th e ai r cra ft i s re gist ered wit h th e Fe dera l Av iati on A dmin istr atio n in acc orda nce with Title 49 of th e U nit ed Sta tes Co de 441 01 et seq. and appli cabl e Fe dera l Av iati on R egul atio ns, and that the air craf t ha s be en i nspe cted and is airw orth y an d el igib le f or t he airwo rthi ness cer tifi cate requ est ed.
A. THE AIRCRAFT DESCRIBED ABOVE HAS BEEN IN SPECTE D AND FO UND AIRWOR THY BY: (Complete this section only if 14 CFR part 21 . 183( d) app lies).
NAME AND TITLE (Print or type) SIGNATURE
DATE TITLE SIGNATURE INSTRUCTIONS - Print or type. Do not write in shaded areas; these are for FAA use only. Submit origi nal only to an authorized FAA Representative. If additional space is required, use attachment. For special flight permits complete Sections II, VI, and VII as applicable.
B. Insp ecti on f or a spe cial fli ght perm it u nder Sec tion VII wa s c ond uct ed by:
6. ENGINE BUILDER 'S NAME (M ake)
9. PROPELLER BUILDER'S NAME (M ake)
5. AIRCR AFT SER IAL NO.
8. NUMBER OF ENGINES
IF DEALER, CHECK HERE AIRCRAFT LISTING (Give page number(s)) SUPPLEMENTAL TYPE CERTIFICAT E (Li st number of each ST C inc orpor ated) AIRCRAFT MANUFACTURER (Give name or firm) U.S. D epa rtm ent of Tr ansp orta tion Federal Aviation Administration Certificate No.)
O.M.B. No. 2120-0018
NORMAL UTILITY ACROBATIC TRANSPORT COMMUTE R BALLOON FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006 C MULTIPLE AIR W ORTHINESS CERTIFICATE (Check ABOVE " Restr icted Oper ation " and "Sta ndard " or "Lim i ted" as ap plica ble.)
X
SPECIAL FLIGHT PERMIT (Indi cate oper ati on to be con duc ted , t hen com ple te S ecti on V I or VII as applica ble o n rev erse side)
LIM ITED PROVIS IONAL (Indicate class) RESTRICTED (Indi cate opera tion( s) to be c ond uct ed)
AGRICULTURE AN D PEST CONTROL FOREST (W ildlife c onservation)
CLAS S I
CLAS S II AERIAL
PATROLLING
AERIAL ADVER TISING
WEATHER CONTROL
AMATEUR BUILT
CREW TRAINING
EXHIBITION
MARKET SURVEY
DELIVERIN G OR EX PORTING
TO SHOW COMPLIAN CE WITH THE CFR
CUSTOMER DEMONSTRATION FLIGHTS
PRODUCTION FLIGHT TESTING
X FERRY FLIGHT FOR R EPAIRS, A LTERATION S, MAINT ENANCE, O R STORAGE
EVACUATE FROM AREA OF IMPENDING DANGER
OPERATION IN EX CESS OF MAX IMUM CERTIF ICATED TAKE -OFF W EIGHT
RESEA RCH AND D EVELOPMENT AIR RACINGEXPERIM ENTAL (Indica te op erati on(s) to b e c ond uct ed) OTHER (Specify) OPERATING (Prim ary Category) KIT BUILT AIRCRAFT
PRIMARY
FAA INSPECTOR 14 CFR par t 65
FAA DE SIGNEE 14 CFR part 121 O R 135 14 CFR pa rt 145
THE CERTIFICA TE REQUESTED
AMENDMENT OR MODIFICATION OF CURRENT AIRWORTHIN ESS CERTIFICATE
CERTIFICATE HOLDER UNDER OTHER1 14 3 6 4 2 5 3 4 8 3 6 3 2 5 1 2 4 1 0 1 4 0 7 6 4 3 2 1 5 7 2 5 6 5 2
Appendix 1 FIGURE 15. SAMPLE FAA FORM 8130-6, APPLICATION FOR A SPECIAL AIRWORTHINESS CERTIFICATE – SPECIAL FLIGHT PERMIT FOR FERRY FLIGHT (REVERSE SIDE) (cont’d.)
PRODUCTION CERTIFICATE (Give produc tion c ertifi cate n um ber)
TYPE CE RTIFICA TE ONLY
APPROVED PROD UCTION INSPE CTION SYSTEM A. DESCRIPTION OF AIRCRAFT VIII. AIRWORTH IN ESS
DOCUMENTA TION (FAA/DES IGNEE use only) VI . PRODUCTION
FLIGHT TESTING B. Current Ope rat ing Li mit ati ons At tac hed C. Data, Draw ings , Photographs, etc. (Attach when requ ired) D. Current W eig ht a nd B alan ce I nfor mati on A vail able in Airc raft E. Major R epa ir a nd A lter atio n, F AA F orm 337 (Attach when required) F. This inspection Rec orded in A ircra ft Records A. Operating Limi tati ons and Mark ings in Comp lian ce w ith 14 C FR s ecti on 9 1.9, as A ppl ica ble H. Foreign Airworthiness Cer tification for Import Aircraft (Attac h when r equi red) I. Previous A irw or thine ss C e rtifi cate Issue d in Accor dance with J. Current Airwor thiness Ce rtifi cate Issued in Accor dance with G. Statement of Con for mit y, FAA Fo rm 813 0-9 (Attach when requ ired)
SERIAL NUMBER 40 99 SIGNATUREDATE OF APPLICATION NAM E AND TITLE (Print or type)
NAME ADDRESS A. MANUFACTURER B. PRODUCTIO N BASIS (Check ap plicabl e item) B. DESCRIPTION OF FLIGHT FROM W aterl oo, Iowa
DEPARTURE DATE 11/3 0/ 96 TO De s Moine s, Io wa DATE 11/2 5/ 96 NAME AND TITLE (Print o r type) Robert F . Tur ner, Ow ner
SIGNATURE X C. CREW REQUIRED TO OPERATE TH E AIRCRAFT AND ITS EQUIPM ENT F. C ER TIFICATION - I hereby certify that I am t he r egis tere d ow ner (or his agen t) o f th e ai rcra ft d escr ibed abo ve; that the air craf t is registered with the Federal Avi ation Admini stra tion in accordance with Ti tle 49 of th e U nit ed Sta tes Co de 441 01 et seq. and applicable Federal Aviatio n R egu lat ion s; and th at the ai rcr aft ha s b een in spe cte d a nd is air wor thy fo r t he fli ght descr ibed.
VIA Direct C. GIVE QUANTITY OF CERTIFICATES R EQUIRED F OR OPERAT ING NEEDS BUILDER (Make) Bellancia
REGISTERED OW NER Robert F. T urner
REGISTRATION MARK N 254B MODE L 14-1 9-2
ADDRESS 4623 Moun tain view D ri ve, W ate rloo , Io w a 5 0701
DURATION 12/0 3/ 96 D. THE AIRC RAFT DOES NOT MEET THE APPLICABLE AIRWORTHINESS REQUIR EMENTS AS FOLLOWS:
Aircraft d amag ed i n la ndin g ac cide nt. Tem pora ry r epai rs h ave been mad e fo r on e fl ight to repa ir s hop at D es M oine s - Dodg e Ai rpor t, w here per mane nt r epai rs w ill be made.
E. THE FOLLOW ING RESTR ICTIONS A RE CONSID ERED NECE SSARY FOR SAFE OPE RATION: ( U se atta chm en t if neces sary)
1. Airspeed sh oul d n ot exc eed 11 5 M PH.
2. Land ing ge ar sho uld no t b e r etr act ed.
3. N o pa ssen gers or carg o sh ould be carr ied.
(C heck if a pplicable)CUSTOMER DEMONSTRATION FLIGHTS PILOT CO-PILOT FLIGHT ENGINEER OTHER (Specify) 14 CFR Section CAR (Origin al Att ached) 14 CFR Section (Copy attached) VII. SPECIAL FLIGHT PERMIT PURPOSES OTHER THAN PRODUCTION FLIGHT TEST FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006
Appendix 1 FIGURE 16. SAMPLE FAA FORM 8130-6, APPLICATION FOR A SPECIAL AIRWORTHINESS CERTIFICATE – SPECIAL FLIGHT PERMIT FOR PRODUCTION
FLIGHT TESTING (FACE SIDE)
APPLICATION FOR
AIRWORTHINESS
CERTIFICATE II. CERTIFICATION REQUESTED EXPERIMEN TAL ONLY (Enter hours flown s ince la st cert ificate CERTIFICATED R EPAIR STATION (Give CertificateCERTIFICATED MECHANIC (Give AIRCRAFT SPECIFICATION O R TYPE CER TIFICATE D ATA SHEET (Give No. and AIRW ORTHINES S DIRECTIVES (Check if all ap plica ble A D's c om pli ed wi th an d giv e the num b er of the last AD SUPP LEM EN T ava ilabl e in the b iweek ly se ries as of the date of ap plica tion) issued or re newed) No.)
Revision No.)
14 CF R part 121 C ERTIFI CATE H OLDER (Give Certificate No.)
A. REGISTE RED OW NER (A s show n on c ertifi cate o f airc raft r egistr ation) V. FAA
REPRESENTATIV E
CERTIFICATION I. AIRCRA FT DE SC RIPTIONIII. OWNER'S CERTIFICATION IV. INSPECTION AGENCY
VERIFIC ATION A B X STANDARD AIRW ORTHINESS CERTIFICATE (Indicate category) SPECIAL AIR W ORTHINESS CERTIFICATE (Check approp riate item s)
1. REGISTR ATION MARK APPLICAT ION IS H EREBY MA DE FOR: (Check a pplicabl e item s)
2. AIRCRAFT BU ILDER'S NAME (M ake) FAA CODING3. AIRCRAFT MODEL DESIGNATION 4. YR. MFR.
7. ENGINE MODEL DESIGNATION
10. PRO PELLER MODEL DESIG NATION
IM PORT
11. AIRC RAFT IS (Check if appl icable) DATE DISTRICT OFFICE DESIGNEE'S SIG NATURE AND NO. FAA INSPECTOR 'S SIGNATURE (Check ALL appli cable bloc ks in item s A a nd B) A. I fin d th at t he a ircr aft desc ribe d in Sec tion I o r VI I me ets requ irem ents for
NAME ADDRESS B. AIRCRAFT CERTIFICATION BASIS (C heck appli cable bloc ks an d com plete item s as indic ated) C. AIRCRAFT OPERATION AND MAINTENANCE RECORDS
CHECK IF RECORDS IN
COMPLIANCE WITH 14 CF R se ctio n 91 .417
TOTAL AIRFRAME HOURS 3
DATE OF APPLICATION D. CERTIFICATION - I hereby certify that I am the regi ster ed o wner (or his age nt) of t he a ircr aft desc ribe d ab ove, tha t th e ai r cra ft i s re gist ered wit h th e Fe dera l Av iati on A dmin istr atio n in acc orda nce with Title 49 of th e U nit ed Sta tes Co de 441 01 et seq . and appli cabl e Fe dera l Av iati on R egul atio ns, and that the air craf t ha s be en i nspe cted and is airw orth y an d el igib le f or t he airwo rthi ness cer tifi cate requ est ed.
A. THE AIRCRAFT DESCRIBED ABOVE HAS BEEN IN SPECTE D AND FO UND AIRWOR THY BY: (Complete this section only if 14 CFR part 21 . 183( d) app lies).
NAME AND TITLE (Print or type) SIGNATURE
DATE TITLE SIGNATURE INSTRUCTIONS - Print or type. Do not write in shaded areas; these are for FAA use only. Submit origi nal only to an authorized FAA Representative. If additional space is required, use attachment. For special flight permits complete Sections II, VI, and VII as applicable.
B. Insp ecti on f or a spe cial fli ght perm it u nder Sec tion VII wa s c ond uct ed by:
6. ENGINE BUILDER 'S NAME (M ake)
9. PROPELLER BUILDER'S NAME (M ake)
5. AIRCR AFT SER IAL NO.
8. NUMBER OF ENGINES
IF DEALER, CHECK HERE AIRCRAFT LISTING (Give page number(s)) SUPPLEMENTAL TYPE CERTIFICAT E (Li st number of each ST C inc orpor ated) AIRCRAFT MANUFACTURER (Give name or firm) U.S. D epa rtm ent of Tr ansp orta tion Federal Aviation Administration Certificate No.)
O.M.B. No. 2120-0018
NORMAL UTILITY ACROBATIC TRANSPORT COMMUTE R BALLOON FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006 C MULTIPLE AIR W ORTHINESS CERTIFICATE (Check ABOVE " Restr icted Oper ation " and "Sta ndard " or "Lim i ted" as ap plica ble.)
x
SPECIAL FLIGHT PERMIT (Indi cate oper ati on to be con duc ted , t hen com ple te S ecti on V I or VII as applica ble o n rev erse side)
LIM ITED PROVIS IONAL (Indicate class) RESTRICTED (Indi cate opera tion( s) to be c ond uct ed)
AGRICULTURE AN D PEST CONTROL FOREST (W ildlife c onservation)
CLAS S I
CLAS S II AERIAL
PATROLLING
AERIAL ADVER TISING
WEATHER CONTROL
AMATEUR BUILT
CREW TRAINING
EXHIBITION
MARKET SURVEY
DELIVERIN G OR EX PORTING
TO SHOW COMPLIAN CE WITH THE CFR
CUSTOMER DEMONSTRATION FLIGHTS
PRODUCTION FLIGHT TESTING
FERRY FLIGHT FOR R EPAIRS, A LTERATION S, MAINT ENANCE, O R STORAGE
EVACUATE FROM AREA OF IMPENDING DANGER
OPERATION IN EX CESS OF MAX IMUM CERTIF ICATED TAKE -OFF W EIGHT
RESEA RCH AND D EVELOPMENT AIR RACINGEXPERIM ENTAL (Indica te op erati on(s) to b e c ond uct ed) x OTHER (Specify) OPERATING (Primary Category) KIT BUILT AIRCRAFT
PRIMARY
FAA INSPECTOR 14 CFR par t 65
FAA DE SIGNEE 14 CFR part 121 O R 135 14 CFR pa rt 145
THE CERTIFICA TE REQUESTED
AMENDMENT OR MODIFICATION OF CURRENT AIRWORTHIN ESS CERTIFICATE
CERTIFICATE HOLDER UNDER OTHER1 14 3 6 4 2 5 3 4 8 3 6 3 2 5 1 2 4 1 0 1 4 0 7 6 4 3 2 1 5 7 2 5 6 6 5 2
Appendix 1 FIGURE 16. SAMPLE FAA FORM 8130-6, APPLICATION FOR A SPECIAL AIRWORTHINESS CERTIFICATE – SPECIAL FLIGHT PERMIT FOR PRODUCTION FLIGHT TESTING (REVERSE SIDE) (cont’d.)
PRODUCTION CERTIFICATE (Give produc tion c ertifi cate n um ber) P C# 700
TYPE CE RTIFICA TE ONLY
APPROVED PROD UCTION INSPE CTION SYSTEM A. DESCRIPTION OF AIRCRAFT VIII. AIRWORTH IN ESS
DOCUMENTA TION (FAA/DES IGNEE use only) VI. PRODUCTION
FLIGHT TESTING B. Current Ope rat ing Li mit ati ons At tac hed C. Data, Draw ings , Photographs, etc. (Attach when requ ired) D. Current W eig ht a nd B alan ce I nfor mati on A vail able in Airc raft E. Major Repa ir a nd A lter atio n, F AA F orm 337 (Attach when required) F. This inspection Rec orded in A ircra ft Records A. Operating Limi tati ons and Mark ings in Comp lian ce w ith 14 C FR s ecti on 9 1.9, as A ppl ica ble H. Foreign Airworthiness Cer tification for Import Aircraft (Attac h when r equi red) I. Previous A irwor thine ss Ce rtifi cate Issue d in Accor dance with J. Current Airwor thiness Ce rtifi cate Issued in Accor dance with G. Statement of Con for mit y, FAA Fo rm 813 0-9 (Attach when requ ired)
SERIAL NUMBER
SIGNATUREDATE OF APPLICATION 11/2 5/ 96 NAME AND TITLE (Print or type) John C. Burn s, P resi dent NAME ABC Airc raft C ompany
ADDRESS 509 M ore land Blv d, P aloma Ne w Yo rk 2 0101 A. MANUFACTURER B. PRODUCTIO N BASIS (Check ap plicabl e item) B. DESCRIPTION OF FLIGHT FROM
DEPARTURE DATE TO DATE NAME AND TITLE (Print o r type) SIGNATURE C. CREW REQUIRED TO OPERATE TH E AIRCRAFT AND ITS EQUIPMENT F. CERTIFICATION - I hereby certify that I am t he r egis tere d ow ner (or his agen t) o f th e ai rcra ft d escr ibed abo ve; that the air craf t is registered with the Federal Avi ation Admini stra tion in accordance with Ti tle 49 of th e U nit ed Sta tes Co de 441 01 et seq. and applicable Federal Aviatio n R egu lat ion s; and th at the ai rcr aft ha s b een in spe cte d a nd is air wor thy fo r t he fli ght descr ibed.
VIA C. GIVE QUANTITY OF CERTIFICATES R EQUIRED F OR OPERAT ING NEEDS BUILDER (Make)
REGISTERED OW NER
REGISTRATION MARK MODEL
ADDRESS
DURATION D. THE AIRC RAFT DOES NOT MEET THE APPLICABLE AIRWORTHINESS REQUIR EMENTS AS FOLLOWS:
E. THE FOLLOW ING RESTR ICTIONS A RE CONSID ERED NECE SSARY FOR SAFE OPE RATION: ( Use atta chm en t if neces sary) (Check if a pplicable)CUSTOMER DEMONSTRATION FLIGHTS PILOT CO-PILOT FLIGHT ENGINEER OTHER (Specify) 14 CFR Section CAR (Origin al Att ached) 14 CFR Section (Copy attached) VII. SPECIAL FLIGHT PERMIT PURPOSES OTHER THAN PRODUCTIO N FLIGHT TEST X FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006
Appendix 1 FIGURE 17. SAMPLE FAA FORM 8130-6, APPLICATION FOR A MULTIPLE
AIRWORTHINESS CERTIFICATE (FACE SIDE ONLY)
APPLICATION FOR
AIRWORTHINESS
CERTIFICATE II. CERTIFICATION REQUE STED EXPERIMEN TAL ONLY (Enter hours flown s ince la st cert ificate CERTIFICATED R EPAIR STATION (Give CertificateCERTIFICATED MECHANIC (Give AIRCRAFT SPECIFICATION O R TYPE CER TIFICATE D ATA SHEET (Give No. and AIRW ORTHINES S DIRECTIVES (Check if all ap plica ble A D's c om pli ed wi th an d giv e the num b er of the las t AD SUPPL EM ENT avai lable in t he bi weekl y ser ies a s of the d ate o f app licat ion) 96- 23 issued or re newed) N/A No.)
Revision No.)
1A2 R ev. 33, AR- 7 Re v. 9 14 CF R part 121 C ERTIFI CATE H OLDER (Give Certificate No.)
A. REGISTE RED OW NER (A s show n on c ertifi cate o f airc raft r egistr ation) V. FAA
REPRESENTATIVE
CERTIFICATION I. AIRCRAFT DESCRIPTIONIII. OWNER'S CERTIFICATION IV. INSPECTION AGENCY
VERIFICATIO N A B X STANDARD AIRW ORTHINESS CERTIFICATE (Indicate category) SPECIAL AIR W ORTHINESS CERTIFICATE (Check approp riate item s)
1. REGISTR ATION MARK N54 321 APPLICAT ION IS H EREBY MA DE FOR: (Check a pplicabl e item s)
2. AIRCRAFT BU ILDER'S NAME (M ake) P iper FAA CODING3. AIRCRAFT MODEL DESIGNATION P A18 A - 150
4. YR. M FR.
1 951
7. ENGINE MODEL DESIGNATION 0- 320
10. PRO PELLER MODEL DESIG NATION M 74DM IM PORT
11. AIRC RAFT IS (Check if appl icable) DATE DISTRICT OFFICE DESIGNEE'S SIG NATURE AND NO. FAA INSPECTOR 'S SIGNATURE (Check ALL appli cable bloc ks in item s A a nd B) A. I fin d th at t he a ircr aft desc ribe d in Sec tion I o r VI I me ets requ irem ents for X X NAME North Ce ntral Airp lane Corp.
ADDRESS Rt.
1 Box 5 02 Cut bac k, M inn. 43 692 B. AIRCRAFT CERTIFICATION BASIS (C heck appli cable bloc ks an d com plete item s as indic ated) X C. AIRCRAFT OPERATION AND MAINTENANCE RECORDS
CHECK IF RECORDS IN
COMPLIANCE WITH 14 CF R se ctio n 91 .417
TOTAL AIRFRAME HOURS 12 ,0 50 3
DATE OF APPLICATION 11/2 1/ 96 D. CERTIFICATION - I hereby certify that I am the regi ster ed o wner (or his age nt) of t he a ircr aft desc ribe d ab ove, tha t th e ai r cra ft i s re gist ered wit h th e Fe dera l Av iati on A dmin istr atio n in acc orda nce with Title 49 of th e U nit ed Sta tes Co de 441 01 et seq. and appli cabl e Fe dera l Av iati on R egul atio ns, and that the air craf t ha s be en i nspe cted and is airw orth y an d el igib le f or t he airwo rthi ness cer tifi cate requ est ed.
A. THE AIRCRAFT DESCRIBED ABOVE HAS BEEN IN SPECTE D AND FO UND AIRWOR THY BY: (Complete this section only if 14 CFR part 21 . 183( d) app lies).
NAME AND TITLE (Print or type) John J one s, Pre sid ent
SIGNATURE
DATE TITLE SIGNATURE INSTRUCTIONS - Print or type. Do not write in shaded areas; these are for FAA use only. Submit origi nal only to an authorized FAA Representative. If additional space is required, use attachment. For special flight permits complete Sections II, VI, and VII as applicable.
B. Insp ecti on f or a spe cial fli ght perm it u nder Sec tion VII wa s c ond uct ed by:
6. ENGINE BUILDER 'S NAME (M ake) Lyco ming
9. PROPELLER BUILDER'S NAME (M ake) Sen sen ich
5. AIRCR AFT SER IAL NO.
1 8- 37 92
8. NUMBER OF ENGINES One
IF DEALER, CHECK HERE AIRCRAFT LISTING (Give page number(s)) N/A SUPPLEMENTAL TYPE CERTIFICAT E (Li st number of each ST C inc orpor ated) AIRCRAFT MANUFACTURER (Give name or firm) U.S. D epa rtm ent of Tr ansp orta tion Federal Aviation Administration Certificate No.)
Form Approved O.M.B. No. 2120-0018
X NORMAL X UTILITY ACROBATIC TRANSPORT COMMUTE R BALLOON FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006 C X MULTIPLE AIR W ORTHINESS CERTIFICATE (Check ABOVE " Restr icted Oper ation " and "Sta ndard " or "Lim i ted" as ap plica ble.)
X SPECIAL FLIGHT PERMIT (Indi cate oper ati on to be con duc ted , t hen com ple te S ecti on V I or VII as applica ble o n rev erse side)
LIM ITED PROVIS IONAL (Indicate class) RESTRICTED (Indi cate opera tion( s) to be c ond uct ed)
AGRICULTURE AN D PEST CONTROL FOREST (W ildlife c onservation)
CLAS S I
CLAS S II AERIAL
PATROLLING
AERIAL ADVER TISING
WEATHER CONTROL
AMATEUR BUILT
CREW TRAINING
EXHIBITION
MARKET SURVEY
DELIVERIN G OR EX PORTING
TO SHOW COMPLIAN CE WITH THE CFR
CUSTOMER DEMONSTRATION FLIGHTS
PRODUCTION FLIGHT TESTING x
FERRY FLIGHT FOR R EPAIRS, A LTERATION S, MAINT ENANCE, O R STORAGE
EVACUATE FROM AREA OF IMPENDING DANGER
OPERATION IN EX CESS OF MAX IMUM CERTIF ICATED TAKE -OFF W EIGHT
RESEA RCH AND D EVELOPMENT AIR RACINGEXPERIM ENTAL (Indica te op erati on(s) to b e c ond uct ed) OTHER (Specify) OPERATING (Prim ary Category) KIT BUILT AIRCRAFT
PRIMARY
FAA INSPECTOR 14 CFR par t 65
FAA DE SIGNEE 14 CFR part 121 O R 135 14 CFR pa rt 145
THE CERTIFICA TE REQUESTED
AMENDMENT OR MODIFICATION OF CURRENT AIRWORTHIN ESS CERTIFICATE
CERTIFICATE HOLDER UNDER OTHER1 14 3 6 4 2 5 3 4 8 3 6 3 2 5 1 2 4 1 0 7 4 0 7 5 4 3 2 1 5 7 2 5 6 5 2