Appendix D Figure D-14. Sample FAA Form 8130-6, Application for U.S. Airworthiness Certificate, Special - Experimental Category, To Show Compliance with CFR (Face Side Only) FAA FORM 8130-6, APPLICATION FOR U.S. AIRWORTHINESS CERTIFICATE Form Approved O.M.B. No. 2120-0018 APPLICATION FOR INSTRUCTIONS - Print or type. Do not write in shaded areas; these are for FAA U.S. Department of Transportation U.S. AIRWORTHINESS use only. Submit original only to an authorized FAA Representative. If additional pace is required, use attachment. For special flight permits complete Sections Federal Aviation CERTIFICATE 1, VI, and VII as applicable Administration REGISTRATION MARK 2. AIRCRAFT BUILDER'S NAME (Make) AIRCRAFT MODEL DESIGNATION 4. YR. MFR FAA CODING AIRCRAFT DESCRIPTION 5. AIRCRAFT SERIAL NO. N654GL 6. ENGINE BUILDER'S NAME (Make) Night Aircraft, LLC 7. ENGINE MODEL DESIGNATION N7-Xray 2009 NX09 TCM IO-360-ES
8. NUMBER OF ENGINES 9. PROPELLER BUILDER'S NAME (Make) 10. PROPELLER MODEL DESIGNATION 11. AIRCRAFT IS (Check if applicable) McCauley Propeller Systems 2A34C209 IMPORT APPLICATION IS HEREBY MADE FOR: (Check applicable items) A 1 STANDARD AIRWORTHINESS CERTIFICATE (Indicate category) NORMAL • UTILITY ACROBATIC TRANSPORT COMMUTER BALLOON OTHER SPECIAL AIRWORTHINESS CERTIFICATE (Check appropriate terms)
PRIMARY LIGHT-SPORT (nacate Class) Airplane Power-Parachute Weight-Shift-Control Glider Lighter than Air
LIMITED PROVISIONAL (indi CLASS I CLASS I| II. CERTIFICATION REQUESTED AGRICULTURE AND PEST CONTROL 2 AERIAL SURVEY AERIAL ADVERTISING RESTRICTED (Indicate operations) to be conducted) FOREST (Wildlife conservation) PATROLLING WEATHER CONTROL OTHER (Specity) RESEARCH AND DEVELOPMENT 2 AMATEUR BUILT 3| EXHIBITION AIR RACING CREW TRAINING 6 MARKET SURVEY 0Y TO SHOW COMPLIANCE WITH THE CFR OPERATING (Primary Category) KIT BUILT AIRCRAFT SA Existing aircraft without an airworthiness certificate & do not meet § 103.1 EXPERIMENTAL (indice OPERATING _ 8B Operating Light-Sport Kit-built
LIGHT-SPORT 8C Operating light-sport previously issued special light-sport category airworthiness certificate under § 21.190 UNMANNED 9A RESEARCH AND DEVELOPMENT 9C CREW TRAINING AIRCRAFT 9B MARKET SURVEY
FERRY FLIGHT FOR REPAIRS, ALTERATIONS, MAINTENANCE, OR STORAGE SPECIAL FLIGHT PERMIT pracate EVACUATE FROM AREA OF IMPENDING DANGER Section VI or VII as appleable on reverse side) OPERATION IN EXCESS OF MAXIMUM CERTIFICATED TAKE-OFF WEIGHT DELIVERING OR EXPORTING 5 PRODUCTION FLIGHT TESTING
CUSTOMER DEMONSTRATION FLIGHTS C 6 MULTIPLE AIRWORTHINESS CERTIFICATE (Check ABOVE "Restricted Operation and "Standard" or "Limited" as applicable) A. REGISTERED OWNER (As shown on certificate of aircraft registration) IF DEALER, CHECK HERE
NAME ADDRESS Mary Test 78 China Drive, Jumping, TX 89765 B. AIRCRAFT CERTIFICATION BASIS (Check applicable blocks and complete ems as indicated) III. OWNER'S CERTIFICATION AIRCRAFT SPECIFICATION OR TYPE CERTIFICATE DATA SHEET (Give No and Revision No.) N/A AIRWORTHINESS DIRECTIVES (Checkif all applicabie ADs are complied with and give the numbe last AD SUPPLEMENT available in the biweekly series as of the date of application AIRCRAFT LISTING (Give page SUPPLEMENTAL TYPE CERTIFICATE (List number of each STC incorporated)
N/A N/A C. AIRCRAFT OPERATION AND MAINTENAN CHECK IF RECORDS IN TOTAL AIRFRAME HOURS EXPERIMENTAL ONLY (Enter hours flown since last certificate issued COMPLIANCE WITH 14 CFR section 91.417 orrenewed o D. CERTIFICATION - I hereby certify that I am the registered owner (or his agent) of the aircraft described above, that the aircraft is registered with the Federal Aviation Administration in accordance with Title 49 of the United States Code 44101 et seg. and applicable Federal Aviation Regulations, and that the aircraft has been inspected and is airworthy and eligible for the airworthiness certificate requested.
DATE OF APPLICATION NAME AND TITLE (Print or type) SIGNATURE 01/27/2010 Mary Test, President Mary Tast A. THE AIRCRAFT DESCRIBED ABOVE HAS BEEN INSPECTED AND FOUND AIRWORTHY BY: (Complete the section only if 14 CFR part 21.183Yd) apples IV. INSPECTION AGENCY VERIFICATION 14 CFR part 121 CERTIFICATE HOLDER (GNe Certificate No) AIRCRAFT MANUFACTURER (Give name or fim) CERTIFICATED MECHANIC (Give Certificate No.) CERTIFICATED REPAIR STATION (GiVe Certicate
DATE TITLE SIGNATURE (Check ALL applicable block tems A and B) THE CERTIFICATE REQUESTED V. FAA REPRESENTATIVE CERTIFICATION B. Inspection for a special flight perit under Section VII A. I find that the aircraft described in Section I or VIl meets requirements for FAA INSPECTOR AMENDMENT OR MODIFICATION OF CURRENT AIRWORTHINESS CERTIFICATE FAA DESIGNEE CERTIFICATE HOLDER UNDER 14 CFR part 65 14 CFR part 121 OR 135 14 CFR part 145 DATE MIDO/FSDO FAA INSPECTOR'S SIGNATURE or DESIGNEE'S FAA INSPECTOR'S CERTIFICATION FILE REVIEW OFFICE SIGNATURE AND NO. SIGNATURE FAA Form 8130-6 (04-11) All Previous Editions Superseded D-15
Appendix D Figure D-15. Sample FAA Form 8130-6, Application for U.S. Airworthiness Certificate, Special - Experimental Category, Amateur-Built, with Type-Certificated Installations (Face Side Only) FAA FORM 8130-6, APPLICATION FOR U.S. AIRWORTHINESS CERTIFICATE Form Approved O.M.B. No. 2120-0018 APPLICATION FOR INSTRUCTIONS - Print or type. Do not write in shaded areas; these are for FAA U.S. Department of Transportation U.S. AIRWORTHINESS use only. Submit original only to an authorized FAA Representative. If additional space is required, use attachment. For special fight permits complete Sections Federal Aviation CERTIFICATE II, VI, and VII as applicable.
Administration
1. REGISTRATION MARK 2. AIRCRAFT BUILDER'S NAME (Make) 3. AIRCRAFT MODEL DESIGNATION 4. YR. MFR FAA CODING AIRCRAFT DESCRIPTION 5. AIRCRAFT SERIAL NO. N12345 6. ENGINE BUILDER'S NAME (Make) Bill Jones 7. ENGINE MODEL DESIGNATION Lancair IV-P 2001 0098 Teledyne Continental Motors TSIO-550-B(1)
8. NUMBER OF ENGINES 9. PROPELLER BUILDER'S NAME (Mate) 10. PROPELLER MODEL DESIGNATION 11. AIRCRAFT IS (Check if applicable) 1 Hartzell Propeller, Inc. PHCHYF 1RF IMPORT APPLICATION IS HEREBY MADE FOR: (Check applicable items) STANDARD AIRWORTHINESS CERTIFICATE (indicate category) NORMAL UTILITY ACROBATIC | TRANSPORT COMMUTER BALLOON OTHER SPECIAL AIRWORTHINESS CERTIFICATE (Check appropriate items)
PRIMARY LIGHT-SPORT (radicade Class) Airplane Power-Parachute Weight-Shift-Control Glider Lighter than Air
LIMITED
CLASS I PROVISIONAL (Indicate class) CLASS I| II. CERTIFICATION REQUESTED AGRICULTURE AND PEST CONTROL AERIAL SURVEY AERIAL ADVERTISING RESTRICTED (Indicate operations) FOREST (Micide conservation) 5 PATROLLING WEATHER CONTROL to be conducted) OTHER (Specity) RESEARCH AND DEVELOPMENT | 2 V AMATEUR BUILT 3 EXHIBITION AIR RACING CREW TRAINING 6 MARKET SURVEY TO SHOW COMPLIANCE WITH THE CFR OPERATING (Primary Category) KIT BUILT AIRCRAFT 8A Existing aircraft without an airworthiness certificate & do not meet § 103.1 EXPERIMENTAL (Indicate qoe to be conducted) OPERATING 8B Operating Light-Sport Kit-built LIGHT-SPORT 8C certificate under § 21.19 Operating light-sport previously issued special light-sport category airworthines UNMANNED 9A RESEARCH AND DEVELOPMENT 9C CREW TRAINING
AIRCRAFT MARKET SURVEY
FERRY FLIGHT FOR REPAIRS, ALTERATIONS, MAINTENANCE, OR STORAGE SPECIAL FLIGHT PERMIT indicate EVACUATE FROM AREA OF IMPENDING DANGER Section Vi or VII as applicable on reverse side) OPERATION IN EXCESS OF MAXIMUM CERTIFICATED TAKE-OFF WEIGHT DELIVERING OR EXPORTING 5 PRODUCTION FLIGHT TESTING
CUSTOMER DEMONSTRATION FLIGHTS MULTIPLE AIRWORTHINESS CERTIFICATE (Check ABOVE " Restricted Operation? and "Standard" or "Limited" as applicable) A. REGISTERED OWNER (As shown on certificate of aircraft registration) IF DEALER, CHECK HERE
NAME ADDRESS Bill Jones 10405 E. Mary Street, Daytona Beach, FL 32114 III. OWNER'S CERTIFICATION B. AIRCRAFT CERTIFICATION AIRCRAFT SPECIFICATION OR TYPE CERTIFICATE DATA SHEET (Give No and Revision No.) N/A and complete Rems as indicated) AIRWORTHINESS DIRECTIVES (Check if all applicable ADs are complied with and give the number of the last AD SUPPLEMENT avallable in the bleekly series as of the date of application 2001-12 AIRCRAFT LISTING (Ge page SUPPLEMENTAL TYPE CERTIFICATE (List number of each STC incorporated)
N/A N/A
AIRCRAFT OPERATION AND MAINTENANCE RECORDS CHECK IF RECORDS IN TOTAL AIRFRAME HOURS EXPERIMENTAL ONLY (Enter hours fiown since last certificate issued COMPLIANCE WITH 14 CFR section 91.417 or renewed O D. CERTIFICATION - I hereby certify that I am the registered owner (or his agent) of the aircraft described above, that the aircraft is registered with the Federal Aviation Administration in accordance with Title 49 of the United States Code 44101 at seg and applicable Federal Aviation Regulations. and that the aircraft has been inspected and is airworthy and eligible for the airworthiness certificate requested DATE OF APPLICATION NAME AND TITLE (Print or type) SIGNATURE 07/16/2001 Bill Jones, Owner Kill Ganes A. THE AIRCRAFT DESCRIBED ABOVE HAS BEEN INSPECTED AND FOUND AIRWORTHY BY: (Complete the section only if 14 CFR part 21.183(d) apples) IV. INSPECTION VERIFICATION 14 CFR part 121 CERTIFICATE HOLDER (Give CERTIFICATED MECHANIC (Give Certificate No.) CE) TIFICATED REPAIR STATION (GNe Corticat Certificate No.)
AIRCRAFT MANUFACTURER (Give name or tim)
SIGNATURE (Check ALL applicable block items A and B THE CERTIFICATE REQUESTED A. I find that the aircraft described in Section I or VII meets requirements for AMENDMENT OR MODIFICATION OF CURRENT AIRWORTHINESS CERTIFICATE B. Inspection for a special flight permit under Section VII CERTIFICATION was conducted by: FAA INSPECTOR FAA DESIGNEE CERTIFICATE HOLDER UNDER 14 CFR part 65 14 CFR part 121 OR 135 14 CFR part 145 DATE MIDO/FSDO AA INSPECTOR'S SIGNATURE or DESIGNEE* FAA INSPECTOR'S CERTIFICATION FILE REVIEV
OFFICE SIGNATURE AND NI SIGNATURE FAA Form 8130-6 (04-11) All Previous Editions Superseded D-16
Appendix D Figure D-16. Sample FAA Form 8130-6, Application for U.S. Airworthiness Certificate, Special - Experimental Category, Operating Light-Sport, Operating Light-Sport Kit-Built Under §21.191(i) (Face Side Only) FAA FORM 8130-6, APPLICATION FOR U.S. AIRWORTHINESS CERTIFICATE Form Approved O.M.B. No. 2120-0018 APPLICATION FOR INSTRUCTIONS - Print or type. Do not write in shaded areas; these are for FAA U.S. Department of Transportation U.S. AIRWORTHINESS use only. Submit original only to an authorized FAA Representative. If additional pace is required, use attachment. For special flight permits complete Sections Federal Aviation CERTIFICATE 1, VI, and VII as applicable Administration REGISTRATION MARK 2. AIRCRAFT BUILDER'S NAME (Make) . AIRCRAFT MODEL DESIGNATION . YR. MFR FAA CODING AIRCRAFT DESCRIPTION 5. AIRCRAFT SERIAL NO. N8514U 6. ENGINE BUILDER'S NAME (Make) P&M Aviation LTD 7. ENGINE MODEL DESIGNATION Quik GT450 2007 8114 Rotax 912 ULS
8. NUMBER OF ENGINES 9. PROPELLER BUILDER'S NAME (Make) 10. PROPELLER MODEL DESIGNATION 11. AIRCRAFT IS (Check if applicable) Warp Drive 68L3HPL IMPORT APPLICATION IS HEREBY MADE FOR: (Check applicable items) A 1 STANDARD AIRWORTHINESS CERTIFICATE (Indicate category) NORMAL • UTILITY ACROBATIC TRANSPORT COMMUTER BALLOON OTHER SPECIAL AIRWORTHINESS CERTIFICATE (Check appropriate tems)
PRIMARY LIGHT-SPORT (nacate Class) Airplane Power-Parachute v Weight-Shift-Control Glider Lighter than Air
LIMITED PROVISIONAL (indicate class) CLASS I
CLASS II II. CERTIFICATION REQUESTED AGRICULTURE AND PEST CONTROL 2 AERIAL SURVEY AERIAL ADVERTISING RESTRICTED (Indicate operations) to be conducted) FOREST (Wildlife conservation) 5 PATROLLING WEATHER CONTROL OTHER (Specity) RESEARCH AND DEVELOPMENT 2 AMATEUR BUILT 3 EXHIBITION AIR RACING CREW TRAINING 6 MARKET SURVEY TO SHOW COMPLIANCE WITH THE CFR OPERATING (Primary Category) KIT BUILT AIRCRAFT < EXPERIMENTAL (Indicate operation(s) SA Existing aircraft without an airworthiness certificate & do not meet § 103.1 OPERATING 8B / Operating Light-Sport Kit-built
LIGHT-SPORT 8C Operating light-sport previously issued special light-sport category airworthiness certificate under § 21.190 UNMANNED 9A RESEARCH AND DEVELOPMENT 9C CREW TRAINING AIRCRAFT 9B MARKET SURVEY
FERRY FLIGHT FOR REPAIRS, ALTERATIONS, MAINTENANCE, OR STORAGE SPECIAL FLIGHT PERMIT pracate EVACUATE FROM AREA OF IMPENDING DANGER Section VI or VII as appleable on reverse side) OPERATION IN EXCESS OF MAXIMUM CERTIFICATED TAKE-OFF WEIGHT DELIVERING OR EXPORTING 5 PRODUCTION FLIGHT TESTING
CUSTOMER DEMONSTRATION FLIGHTS C 6 MULTIPLE AIRWORTHINESS CERTIFICATE (Check ABOVE "Restricted Operation and "Standard" or "Limited" as applicable) A. REGISTERED OWNER (As shown on certificate of aircraft registration) IF DEALER, CHECK HERE
NAME ADDRESS Dean Wermer 2907 N 78 Place, Bethel, KS 66109 B. AIRCRAFT CERTIFICATION BASIS (Check applicable blocks and complete tems as indicated) III. OWNER'S CERTIFICATION AIRCRAFT SPECIFICATION OR TYPE CERTIFICATE DATA SHEET (Give No and AIRWORTHINESS DIRECTIVES (Checkif all applicabie ADs are complied with and give the number AIRCRAFT LISTING (Give page number(s)) Reviskon No/ F2317/F2317M-05 2007-17, NONE SUPPLEMENTAL TYPE CERTIFICATE (List number of each STC incorporated) last AD SUPPLEMENT available in the biweekly series as of the date of application
N/A N/A C. AIRCRAFT OPERATION AND MAINTENANCE RECORDS CHECK IF RECORDS IN TOTAL AIRFRAME HOURS EXPERIMENTAL ONLY (Enter hours flown since last certificate issued COMPLIANCE WITH 14 CFR section 91.417 orrenewed o D. CERTIFICATION - I hereby certify that I am the registered owner (or his agent) of the aircraft described above, that the aircraft is registered with the Federal Aviation Administration in accordance with Title 49 of the United States Code 44101 et seg. and applicable Federal Aviation Regulations, and that the aircraft has been inspected and is airworthy and eligible for the airworthiness certificate requested.
DATE OF APPLICATION NAME AND TITLE (Print or type) SIGNATURE 09/01/2007 Dean Wermer, Owner Dear Werme A. THE AIRCRAFT DESCRIBED ABOVE HAS BEEN INSPECTED AND FOUND AIRWORTHY BY: (Complete the section only if 14 CFR part 21.183Yd) apples IV. INSPECTION AGENCY VERIFICATION 14 CFR part 121 CERTIFICATE HOLDER (GNe Certificate No) AIRCRAFT MANUFACTURER (Give name or fim) CERTIFICATED MECHANIC (Give Certificate No.) CERTIFICATED REPAIR STATION (GiVe Certicate
DATE TITLE SIGNATURE (Check ALL applicable block tems A and B) THE CERTIFICATE REQUESTED V. FAA REPRESENTATIVE CERTIFICATION B. Inspection for a special flight perit under Section VII A. I find that the aircraft described in Section I or VIl meets requirements for FAA INSPECTOR AMENDMENT OR MODIFICATION OF CURRENT AIRWORTHINESS CERTIFICATE FAA DESIGNEE CERTIFICATE HOLDER UNDER 14 CFR part 65 14 CFR part 121 OR 135 14 CFR part 145 DATE MIDO/FSDO FAA INSPECTOR'S SIGNATURE or DESIGNEE'S FAA INSPECTOR'S CERTIFICATION FILE REVIEW
OFFICE SIGNATURE AND NO SIGNATURE FAA Form 8130-6 (04-11) All Previous Editions Superseded D-17
Appendix D Figure D-17. Sample FAA Form 8130-6, Application for U.S. Airworthiness Certificate, Special - Experimental Category, Unmanned Aircraft (Face Side Only) FAA FORM 8130-6, APPLICATION FOR U.S. AIRWORTHINESS CERTIFICATE Form Approved O.M.B. No. 2120-0018 APPLICATION FOR INSTRUCTIONS - Print or type. Do not write in shaded areas; these are for FAA U.S. Department of Transportation U.S. AIRWORTHINESS use only. Submit original only to an authorized FAA Representative. If additional space is required, use attachment. For special flight permits complete Sections Federal Aviation CERTIFICATE II, VI, and VIl as applicable.
Administration REGISTRATION MARK 2. AIRCRAFT BUILDER'S NAME (Make) AIRCRAFT MODEL DESIGNATION 4. YR. MFR FAA CODING AIRCRAFT DESCRIPTION 5. AIRCRAFT SERIAL NO. N9876 6. ENGINE BUILDER'S NAME (Make) General Atomics 7. ENGINE MODEL DESIGNATION Altair 2003 AA001 Honeywell International TPE33-10T
8. NUMBER OF ENGINES 9. PROPELLER BUILDER'S NAME (Make) 10. PROPELLER MODEL DESIGNATION 11. AIRCRAFT IS (Check if applicable) McCauley Propeller Systems 3GFR36C606-B IMPORT APPLICATION IS HEREBY MADE FOR: (Check applicable items) STANDARD AIRWORTHINESS CERTIFICATE (Indicate category) NORMAL •UTILITY ACROBATIC COMMUTER BALLOON OTHER SPECIAL AIRWORTHINESS CERTIFICATE (Check appropriate ters)
PRIMARY LIGHT-SPORT (nacate Crass) Airplane Pover-Parachute Weight-Shif-Control T Glider Lighter than Air
LIMITED PROVISIONAL (indicate class) CLASS I
CLASS II II. CERTIFICATION REQUESTED AGRICULTURE AND PEST CONTROL 2 AERIAL SURVEY AERIAL ADVERTISING RESTRICTED (Indicate operations) to be conducted) FOREST (Wildlife conservation) PATROLLING WEATHER CONTROL OTHER (Specity) RESEARCH AND DEVELOPMENT 2 AMATEUR BUILT 3 EXHIBITION AIR RACING CREW TRAINING 6 MARKET SURVEY TO SHOW COMPLIANCE WITH THE CFR OPERATING (Primary Category) KIT BUILT AIRCRAFT < EXPERIMENTAL (Indcate operation(s) SA Existing aircraft without an airworthiness certificate & do not meet § 103.1 OPERATING 8B Operating Light-Sport Kit-built
LIGHT-SPORT 8C Operating light-sport previously issued special light-sport category airworthines certificate under § 21.190 9 V UNMANNED AIRCRAFT 9A 9B / MARKET SURVEY / RESEARCH AND DEVELOPMENT 9CY CREW TRAINING
FERRY FLIGHT FOR REPAIRS, ALTERATIONS, MAINTENANCE, OR STORAGE SPECIAL FLIGHT PERMIT pinacate EVACUATE FROM AREA OF IMPENDING DANGER Section VI or VII as applicable on reverse side) OPERATION IN EXCESS OF MAXIMUM CERTIFICATED TAKE-OFF WEIGHT DELIVERING OR EXPORTING 5 PRODUCTION FLIGHT TESTING
CUSTOMER DEMONSTRATION FLIGHTS C 6 MULTIPLE AIRWORTHINESS CERTIFICATE (Check ABOVE "Restricted Operatior and "Standard" or "Limited" as applicable) A. REGISTERED OWNER (As shown on certificate of aircraft registration) IF DEALER, CHECK HERE→
NAME ADDRESS General Atomics Corp. P.O Box 138, San Diego, CA 90804 B. AIRCRAFT CERTIFICATION BASIS (Check applicable blocks and complete items as indicated) III. OWNER'S CERTIFICATION AIRCRAFT SPECIFICATION OR TYPE CERTIFICATE DATA SHEET (Give No and Revision Na) N/A AIRWORTHINESS DIRECTIVES (Check if all applicable ADs are compled with and give the number 2010-2 SUPPLEMENT alien the wely ses the set pocatin) AIRCRAFT LISTING (Give page ne SUPPLEMENTAL TYPE CERTIFICATE (List number of each STC Incorporated)
N/A N/A C. AIRCRAFT OPERATION AND MAINTENAN CHECK IF RECORDS IN TOTAL AIRFRAME HOURS EXPERIMENTAL ONLY (Enter hours flown since last certificate issued COMPLIANCE WITH 14 CFR section 91.417 505 or renewed 58 D. CERTIFICATION - I hereby certify that I am the registered owner (or his agent) of the aircraft described above, that the aircraft is registered with the Federal Aviation Administration in accordance with Title 49 of the United States Code 44101 et seg. and applicable Federal Aviation Regulations, and that the aircraft has been inspected and is airworthy and eligible for the airworthiness certificate requested.
DATE OF APPLICATION NAME AND TITLE (Print or type) SIGNATURE 12/15/2010 R.L. Brown, Operations Manager RL Braver A. THE AIRCRAFT DESCRIBED ABOVE HAS BEEN INSPECTED AND FOUND AIRWORTHY BY: (Complete the section only if 14 CFR part 21.183Y0) apples IV. INSPECTION VERIFICATION 14 CFR part 121 CERTIFICATE HOLDER (GNe CERTIFICATED MECHANIC (Give Certificate No.) CERTIFICATED REPAIR STATION (Give Certificate AGENCY Certificate No) AIRCRAFT MANUFACTURER (Give name or fim)
DATE TITLE SIGNATURE (Check ALL applicable block tems A and B) THE CERTIFICATE REQUESTED V. FAA REPRESENTATIVE CERTIFICATION B. Inspection for a special flight perit under Section VII A. I find that the aircraft described in Section I or VIl meets requirements for was conducted by: FAA INSPECTOR AMENDMENT OR MODIFICATION OF CURRENT AIRWORTHINESS CERTIFICATE FAA DESIGNEE CERTIFICATE HOLDER UNDER 14 CFR part 65 14 CFR part 121 OR 135 14 CFR part 145 DATE MIDO/FSDO FAA INSPECTOR'S SIGNATURE or DESIGNEE'S FAA INSPECTOR'S CERTIFICATION FILE REVIEW
OFFICE SIGNATURE AND NO SIGNATURE FAA Form 8130-6 (04-11) All Previous Editions Superseded D-18
Appendix D Figure D-18a. Sample FAA Form 8130-6, Application for U.S. Airworthiness Certificate, Special - Special Flight Permit for Ferry Flight for Repairs, Alterations, Maintenance, or Storage (Face Side) FAA FORM 8130-6, APPLICATION FOR U.S. AIRWORTHINESS CERTIFICATE Form Approved O.M.B. No. 2120-0018 APPLICATION FOR INSTRUCTIONS - Print or type. Do not write in shaded areas; these are for FAA we Deparen U.S. AIRWORTHINESS use only. Submit original only to an authorized FAA Representative. If additional of Transportation space is required, use attachment. For special fight permits complete Sections Federal Aviation CERTIFICATE II, VI, and Vil as applicable.
Administration
1. REGISTRATION MARK 2. AIRCRAFT BUILDER'S NAME (Make) 3. AIRCRAFT MODEL DESIGNATION 4. YR. MFR FAA CODING I. AIRCRAFT DESCRIPTION 5. AIRCRAFT SERIAL NO. 6. ENGINE BUILDER'S NAME (MaRe) 7. ENGINE MODEL DESIGNATION
8. NUMBER OF ENGINES 9. PROPELLER BUILDER'S NAME (Make) 10. PROPELLER MODEL DESIGNATION 11. AIRCRAFT IS /Chet
TIMPORT APPLICATION IS HEREBY MADE FOR: (Check applicable Nems) A 1 T STANDARD AIRWORTHINESS CERTIFICATE (indicate category) SPECIAL AIRWORTHINESS CERTIFICATE (Check appropriate tems)
PRIMARY LIGHT-SPORT (indicate Class) | Airplane Power-Parachute Weight-Shift-Control Glider Lighter than Air
LIMITED
CLASS I PROVISIONAL (indicate class)
CLASS II II. CERTIFICATION REQUESTED AGRICULTURE AND PEST CONTROL AERIAL SURVEY 3 AERIAL ADVERTISING RESTRICTED (indicate operationys) to be conducted) FOREST (Wildlife conservation) PATROLLING WEATHER CONTROL OTHER (Specity)
RESEARCH AND DEVELOPMENT AMATEUR BUILT EXHIBITION AIR RACING CREW TRAINING 6 MARKET SURVEY TO SHOW COMPLIANCE WITH THE CFR OPERATING (Primary Category) KIT BUILT AIRCRAFT _ 8A Existing aircraft without an airworthiness certificate & do not meet § 103.1 EXPERIMENTAL (Inck PERATIN 8B Operating Light-Sport Kit-built
IGHT-SPOR 8C Operating light-sport previously issued special light-sport category airworthiness certificate under § 21.190 UNMANNED 94 RESEARCH AND DEVELOPMENT 9C CREW TRAINING AIRCRAFT 9B MARKET SURVEY
V FERRY FLIGHT FOR REPAIRS, ALTERATIONS, MAINTENANCE, OR STORAGE SPECIAL FLIGHT PERMIT (indieate 2 EVACUATE FROM AREA OF IMPENDING DANGER operation to be conducted, then complete Section VI or Vil as applicable on reverse side) OPERATION IN EXCESS OF MAXIMUM CERTIFICATED TAKE-OFF WEIGHT DELIVERING OR EXPORTING 5 PRODUCTION FLIGHT TESTING
CUSTOMER DEMONSTRATION FLIGHTS SS CERTIFICATE (Check ABOVE "Restricted Operation and "Standard or "Limited as applicable) A REGISTERED OWNER (43 S raft registration IF DEALER, CHECK HERE
NAME ADDRESS III. OWNER'S CERTIFICATION B. AIRCRAFT CE AIRCRAFT SPECIFICATION OR TYPE CERTIFICATE DATA SHEET (Give No and id complete items as indicated) AIRWORTHINESS DIRECTIVES (Check it all applicable ADS are complied with and give the number Revision No.) of the last AD SUPPLEMENT available in the biweekdy series as of the date of application) AIRCRAFT LISTING (Give page n SUPPLEMENTAL TYPE CERTIFICATE (List number of each STC Incorporated) . AIRCRAFT ATION AND MAINTENANCE RECORDS CHECK IF RECORDS IN TOTAL AIRFRAME HOURS EXPERIMENTAL ONLY (Enter hours flown since last certificate issued
COMPLIANCE WITH 14 CFR section 91 417 D. CERTIFICATION - I hereby certify that I am the registered owner (or his agent) of the aircraft described above, that the aircraft is registered with the Federal Aviation Administration in acoordance with Title 49 of the United States Code 44101 1 at seg and applicable Federal Aviation Regulations, and that the aircraft has been inspected and is airworthy and eligible for the airworthiness certificate requested DATE OF APPLICATION NAME AND TITLE (Print or type) SIGNATURE A. THE AIRCRAFT DESC EN INSPECTED AND FOUND AIRWORTHY BY: (Complete the section only if 14 CFR part 21.183yg) apples, IV. INSPECTION 14 CFR part 121 CERTI FICATE HOLDER (GiVe CERTIFICATED MECHANIC (Give Certificate No.) CERTIFICATED REPAIR STATION (Give Certicate Certificate No.
AIRCRAFT MANUFACTURER (Give name or firm)
DATE TITLE SIGNATURE (Check ALL applicable block items A and B) THE CERTIFICATE REQUESTED V. FAA REPRESENTATIVE PERTIFICATION A. I find that the aircraft described in Section I or VIl meets requirements for FAA INSPECTOR AMENDMENT OR MODIFICATION OF CURRENT AIRWORTHINESS CERTIFICATE FAA DESIGNEE CERTIFICATE HOLDER UNDER 14 CFR part 65 14 CFR part 121 OR 135 14 CFR part 145 DATE MIDO/FSDO FAA INSPECTOR'S SIGNATURE or DESIGNEE'S FAA INSPECTOR'S CERTIFICATION FILE REVIEW
OFFICE SIGNATURE AND NO SIGNATURE FAA Form 8130-6 (04-11) All Previous Editions Superseded D-19
Appendix D Figure D-18b. Sample FAA Form 8130-6, Application for U.S. Airworthiness Certificate, Special - Special Flight Permit for Ferry Flight for Repairs, Alterations, Maintenance, or Storage (Reverse Side) (cont'd.)
A. MANUFACTURER
NAME ADDRESS VI. PRODUCTION FLIGHT TESTING B. PRODUCTION BASIS (Check applicable item) PRODUCTION CERTIFICATE (Give production certificate number)
TYPE CERTIFICATE OTHER:
C. GIVE QUANTITY OF CERTIFICATES REQUIRED FOR OPERATING NEEDS DATE OF APPLICATION NAME AND TITLE (Print or type) SIGNATURE A. DESCRIPTION OF AIRCRAFT
REGISTERED OWNER Robert F. Turner 4623 Mountainview Drive, Waterloo, IA 50701 BUILDER (Make) MODEL Bellanca 14-19-2
SERIAL NUMBER REGISTRATION MARK 4099 N254B B. DESCRIPTION OF FLIGHT CUSTOMER DEMONSTRATION FLIGHTS • (Check if applicable) VII. SPECIAL FLIGHT PERMIT PURPOSES OTHER THAN PRODUCTION FLIGHT TEST FROM TO Waterloo, IA Des Moines, IA
VIA DEPARTURE DATE DURATIO 11/20/2009 1 da C. CREW REQUIRED TO OPERATE THE AIRCRAFT AND ITS EQUIPMENT V PILOT CO-PILOT T FLIGHT ENGINEER 1 OTHER (Spec.fy) D. THE AIRCRAFT DOES NOT MEET THE APPLICABLE AIRWORTHINESS REQUIREMENTS AS FOLLOWS:
Aircraft damaged in landing accident. Temporary repairs have been made for one flight to repair shop at Des Moines - Dodge Airport, where permanent repairs will be made E. THE FOLLOWING RESTR IDERED NECESSART FOR
1. Airspeed should not exceed 115 MPH 2 Landing gear should not be retracted
3. No passengers or cargo should be carried.
F. CERTIFICATION - I hereby certify that I am the registered owner (or his agent) of the aircraft described above; that the aircraft is registered with the Federal Aviation Administration in accordance with Title 49 of the United States Code 44101 et seg and applicable Federal Aviation Regulations; and that the aircraft has been inspected and is safe for the flight described.
DATE NAME AND TITLE (Print or type) SIGNATURE 11/10/2009 Robert F. Turner, Owner Rabert F. Turner DOCUMENTATION (FAA/DESIGNEE A. Operating Limitations and Markings in Compliance With 14 CFR Section 91.9, As Applicable G. Statement of Conformity, FAA Form 8130-9 (Affach when required) H. Foreign Airworthiness Certification for Import Aircraft VIII. AIRWORTHINESS B. Current Operating Limitations Attached (Attach when required) use only) C. Data, Drawings, Photographs, etc. (Attach when required) I. Previous Airworthiness Certificate Issued in Accordance With 14 CFR Section _ CAR. _ (Original attached) D. Current Weight and Balance Information Available in Aircraft J. Current Airworthiness Certificate Issued in Accordance With E. Major Repair and Alteration, FAA For 337 (Attach when required) 14 CFR Section _ (Copy affeched) F. This inspection Recorded in Aircraft Records K. Light-Sport Aircraft Statement of Compliance, FAA Fom 8130-15 (Attach when required) FAA Form 8130-6 (04-11) All Previous Editions Superseded D-20
Appendix D Figure D-19a. Sample FAA Form 8130-6, Application for U.S. Airworthiness Certificate, Special - Special Flight Permit for Ferry Flight in Excess of Maximum Take-Off Weight (Face Side) FAA FORM 8130-6, APPLICATION FOR U.S. AIRWORTHINESS CERTIFICATE Form Approved O.M.B. No. 2120-0018 APPLICATION FOR INSTRUCTIONS - Print or type. Do not write in shaded areas; these are for FAA of Transportation U.S. AIRWORTHINESS use only. Submit original only to an authorized FAA Representative. If additional space is required, use attachment. For special flight permits complete Sections Federal Aviation CERTIFICATE II, VI, and VIl as applicable.
Administration
1. REGISTRATION MARK 2. AIRCRAFT BUILDER'S NAME (Make) 3. AIRCRAFT MODEL DESIGNATION 4. YR. MFR FAA CODING AIRCRAFT DESCRIPTION 5. AIRCRAFT SERIAL NO. 6. ENGINE BUILDER'S NAME (Make) 7. ENGINE MODEL DESIGNATION
8. NUMBER OF ENGINES 9. PROPELLER BUILDER'S NAME (Make) 10. PROPELLER MODEL DESIGNATION 11. AIRCRAFT IS (Check if applicable) IMPORT APPLICATION IS HEREBY MADE FOR: (Check applicable items) STANDARD AIRWORTHINESS CERTIFICATE (Indicate category) NORMAL _ UTILITY ACROBATIC TRANSPORT COMMUTER BALLOON OTHER SPECIAL AIRWORTHINESS CERTIFICATE (Check appropriate #ems)
PRIMARY LIGHT-SPORT (nadicate Class) Airplane Power-Parachute Weight-Shif-Control Glider Lighter than Air
LIMITED
PROVISIONAL ( CLASS I
CLASS II II. CERTIFICATION REQUESTED AGRICULTURE AND PEST CONTROL 2 AERIAL SURVEY AERIAL ADVERTISING 3 RESTRICTED (Indicate FOREST (Wildlife conservation) 5 PATROLLING WEATHER CONTROL to de conducted) OTHER (Specity) RESEARCH AND DEVELOPMENT 2 AMATEUR BUILT 3 EXHIBITION AIR RACING CREW TRAINING 6 MARKET SURVEY TO SHOW COMPLIANCE WITH THE CFR OPERATING (Primary Category) KIT BUILT AIRCRAFT 8A Existing aircraft without an airworthiness certificate & do not meet § 103.1 EXPERIMENTAL (Indicate oper OPERATING 8B Operating Light-Sport Kit-built LIGHT-SPORT 8C Operating light-sport previously issued special light-sport category airworthines certificate under § 21.19 UNMANNED 9A RESEARCH AND DEVELOPMENT 9C CREW TRAINING AIRCRAFT 9B MARKET SURVEY
FERRY FLIGHT FOR REPAIRS, ALTERATIONS, MAINTENANCE, OR STORAGE SPECIAL FLIGHT PERMIT pinaleate 2 EVACUATE FROM AREA OF IMPENDING DANGER Section Vi or VII as applicable on reverse side) 3 / OPERATION IN EXCESS OF MAXIMUM CERTIFICATED TAKE-OFF WEIGHT DELIVERING OR EXPORTING 15 PRODUCTION FLIGHT TESTING
CUSTOMER DEMONSTRATION FLIGHTS MULTIPLE IPLE AIRWORTHINESS (Check ABOVE "Restricted Operation? and "Standard" or Limited" as applicable) A. REGISTERED OWNER (As shown on certificate of aircraft registratiov) IF DEALER, CHECK HERE →
NAME ADDRESS III. OWNER'S CERTIFICATION B. AIRCRAFT CERTIFICATION B AIRCRAFT SPECIFICATION OR TYPE CERTIFICATE DATA SHEET (Gle No and blocks and complete tems as indicated) AIRWORTHINESS DIRECTIVES (Check if all applicable ADs are complied with and give the number Revision No. of the last AD SUPPLEMENT available in the biweekly series as of the date of application) AIRCRAFT LISTING (Gve page SUPPLEMENTAL TYPE CERTIFICATE (List number of each ST C incorporated)
AND MAINTENANCE RECORDS CHECK IF RECORDS IN TOTAL AIRFRAME HOURS EXPERIMENTAL ONLY (Enter hours flown since last certificate issued 14 CFR section 91.417 D. CERTIFICATION - I hereby certify that I am the registered owner (or his agent) of the aircraft described above, that the aircraft is registered with the Federal Aviation Administration in accordance with Title 49 of the United States Code 44101 et seg. and applicable Federal Aviation Regulations, and that the aircraft has been inspected and is airworthy and eligible for the airworthiness certificate requested.
DATE OF APPLICATION NAME AND TITLE (Print or type) SIGNATURE IV. INSPECTION VERIFICATION A. THE AIRCRAFT DESCRIBED ABOVE HAS BEEN INSPECTED AND FOUND AIRWORTHY BY: (Complete the section only if 14 CFR part 21.183(d) applies) 14 CFR part 121 CERTIFICATE HOLDER (GNe CERTIFICATED MECHANIC (Give Certificate No.) CERTIFICATED REPAIR STATION (Give Certicate AGENCY AIRCRAFT MANUFACTURER (Give name or fim) Certificate No.)
DATE TITLE SIGNATURE (Check ALL applicable block items A and B) THE CERTIFICATE REQUESTED V. FAA REPRESENTATIVE CERTIFICATION B. Inspection for a special flight permit under Section VII A. I find that the aircraft described in Section I or VIl meets requirements for was conducted by: FAA INSPECTOR AMENDMENT OR MODIFICATION OF CURRENT AIRWORTHINESS CERTIFICATE FAA DESIGNEE CERTIFICATE HOLDER UNDER 14 CFR part 65 14 CFR part 121 OR 135 14 CFR part 145 DATE MIDO/FSDO FAA INSPECTOR'S SIGNATURE or DESIGNEE'S FAA INSPECTOR'S CERTIFICATION FILE REVIEW OFFICE SIGNATURE AND NO. SIGNATURE FAA Form 8130-6 (04-11) All Previous Editions Superseded D-21
Appendix D Figure D-19b. Sample FAA Form 8130-6, Application for U.S. Airworthiness Certificate, Special - Special Flight Permit for Ferry Flight in Excess of Maximum Take-Off Weight (Reverse Side) (cont'd.)
A MANUFACTURER
NAME ADDRESS B. PRODUCTION BASIS (Check applicable item) PRODUCTION CERTIFICATE (Give production certificate number)
TYPE CERTIFICATE OTHER C. GIVE QUANTITY OF CERTIFICATES REQUIRED FOR OPERATING NEEDS DATE OF APPLICATION NAME AND TITLE (Print or type) SIGNATURE A. DESCRIPTION OF AIRCRAFT
REGISTERED OWNER ADDRESS Weldon H. Jackson P.O. Box 945, Maui, HI 96782 BUILDER (Make) MODEL Piper PA 23-250F
SERIAL NUMBER REGISTRATION MARK 27-4173 N4588P B. DESCRIPTION OF FLIGHT CUSTOMER DEMONSTRATION FLIGHTS • (Check if applicable) FROM
ELP HNL
VIA URE DATE SJC 11/20/2009 10 days C. CREW REQUIRED TO OPERATE THE AIRCRAFT AND ITS EQUIPMENT V PILOT CO-PILOT FLIGHT ENGINEER OTHER (Specify) D. THE AIRCRAFT DOES NOT MEET THE APPLICABLE AIRWORTHINESS REQUIREMENTS AS FOLLOWS:
Temporary Ferry Fuel System installed in accordance with FAA Form 337, "Major Repair and Alteration" dated 11/5/2009.
Gross weight not to exceed 110% of certified takeoff weight.
echient a necesse y.
1. When the aircraft is in an overweight condition, the design cruise speed should not exceed 162 MPH.
2. The fuel quantity should not exceed 120 gallons in the forward tank and 35 gallons in the aft tank
3. The sequence of use of the ferry tanks shall be as shown by a temporary placard installed in full view of the pilot.
F. CERTIFICATION - I hereby certify that I am the registered owner (or his agent) of the aircraft described above; that the aircraft is registered with the Federal Aviation Administration in accordance with Title 49 of the United States Code 44101 et sag, and applicable ederal Aviation Regulations; and that the aircraft has been inspected and is sate for the flight described.
DATE NAME AND TITLE (Print or type) SIGNATURE 11/10/2009 Dan Brown, Agent DOCUMENTATION (FAA/DESIGNEE A. Operating Limitations and Markings in Compliance With 14 CFR Section 91.9. As Applicable G. Statement of Conformity, FAA Form 8130-9 (Attach when required) H. Foreign Airworthiness Certification for Import Aircraft VIII. AIRWORTHINESS B. Current Operating Limitations Attached (Attach when required) use only) C. Data, Drawings, Photographs, etc. (Attach when required) 1. Previous Airworthiness Certificate Issued in Accordance With 14 CFR Section _ CAR. _ (Original attached) D. Current Weight and Balance Infomation Available in Aircraft J. Current Airworthiness Certificate Issued in Accordance With E. Major Repair and Alteration, FAA For 337 (Affach when required) 14 CFR Section (Copy attached) F. This inspection Recorded in Aircraft Records K. Light-Sport Aircraft Statement of Compliance, FAA For 8130-15 (Attach when required) FAA Form 8130-6 (04-11) All Previous Editions Superseded D-22
Appendix D Figure D-20a. Sample FAA Form 8130-6, Application for U.S. Airworthiness Certificate, Special - Special Flight Permit for Production Flight Testing (Face Side) FAA FORM 8130-6, APPLICATION FOR U.S. AIRWORTHINESS CERTIFICATE Form Approved O.M.B. No. 2120-0018 APPLICATION FOR INSTRUCTIONS - Print or type. Do not write in shaded areas; these are for FAA U.S. Department of Transportation U.S. AIRWORTHINESS use only. Submit original only to an authorized FAA Representative. If additional space is required, use attachment. For special flight permits complete Sections Federal Aviation CERTIFICATE II, VI, and VIl as applicable.
Administration
1. REGISTRATION MARK 2. AIRCRAFT BUILDER'S NAME (Make) 3. AIRCRAFT MODEL DESIGNATION 4. YR. MFR FAA CODING I. AIRCRAFT DESCRIPTION 5. AIRCRAFT SERIAL NO. 6. ENGINE BUILDER'S NAME (Make) 7. ENGINE MODEL DESIGNATION
8. NUMBER OF ENGINES 9. PROPELLER BUILDER'S NAME (Make) 10. PROPELLER MODEL DESIGNATION 11. AIRCRAFT IS (Check if applicable) IMPORT APPLICATION IS HEREBY MADE FOR: (Check applicable items) STANDARD AIRWORTHINESS CERTIFICATE (indicate category) • NORMAL UTILITY ACROBATIC _ TRANSPORT COMMUTER BALLOON OTHER SPECIAL AIRWORTHINESS CERTIFICATE (Check appropriate tems)
PRIMARY LIGHT-SPORT (nacate Crass) Airplane Power-Parachute Weight-Shift-Control • Glider Lighter than Air
LIMITED
PROVISIONAL / CLASS I CLASS I| II. CERTIFICATION REQUESTED AGRICULTURE AND PEST CONTROL 2 AERIAL SURVEY AERIAL ADVERTISING 3 RESTRICTED (Indicate to be conducted) FOREST (Widlife conservation) PATROLLING WEATHER CONTROL OTHER (Specity)
RESEARCH AND DEVELOPMENT AMATEUR BUILT EXHIBITION AIR RACING CREW TRAINING 6 MARKET SURVEY TO SHOW COMPLIANCE WITH THE CFR 7. OPERATING (Primary Category) KIT BUILT AIRCRAFT 8A - Existing aircraft without an airworthiness certificate & do not meet § 103,1 EXPERIMENTAL (Indicate oper OPERATING 8B Operating Light-Sport Kit-built
LIGHT-SPORT 8C Operating light-sport previously issued special light-sport category airworthiness certificate under § 21.190 UNMANNED 9A RESEARCH AND DEVELOPMENT 9C CREW TRAINING AIRCRAFT 9B MARKET SURVEY
FERRY FLIGHT FOR REPAIRS, ALTERATIONS, MAINTENANCE, OR STORAGE SPECIAL FLIGHT PERMIT (nacate EVACUATE FROM AREA OF IMPENDING DANGER Section VI or VII as applicable on reverse side OPERATION IN EXCESS OF MAXIMUM CERTIFICATED TAKE-OFF WEIGHT DELIVERING OR EXPORTING 15 / PRODUCTION FLIGHT TESTING
CUSTOMER DEMONSTRATION FLIGHTS MULTIPLE AIRVORTHINESS CERTIFICATE (Check ABOVE "Restricted Operation and "Standard" or "Limited" as applicable) A. REGISTERED OWNER (As shown on certificate of aircraft registration) IF DEALER, CHECK HERE
NAME ADDRESS III. OWNER'S CERTIFICATION B. AIRCRAFT CERTIF AIRCRAFT SPECIFICATION OR TYPE CERTIFICATE DATA SHEET (Give No and is and complete items as indicated) AIRWORTHINESS DIRECTIVES (Check if all applicable ADs are complied with and give the number Revision No.) of the last AD SUPPLEMENT available in the biweekdy series as of the date of application AIRCRAFT LISTING (Give page SUPPLEMENTAL TYPE CERTIFICATE (List number of each STC incorporated)
• AIRCRAFT OPERATION AND MAINTENANO CHECK IF RECORDS IN TOTAL AIRFRAME HOURS EXPERIMENTAL ONLY (Enter hours flown since last certificate issued
COMPLIANCE WITH 14 CFR section 91.417 D. CERTIFICATION - I hereby certify that I am the registered owner (or his agent) of the aircraft described above, that the aircraft is registered with the Federal Aviation Administration in accordance with Title 49 of the United States Code 44101 et seg. and applicable Federal Aviation Regulations, and that the aircraft has been inspected and is airworthy and eligible for the airworthiness certificate requested.
DATE OF APPLICATION NAME AND TITLE (Print or type) SIGNATURE IV. INSPECTION VERIFICATION A. THE AIRCRAFT DESCRIBED ABOVE HAS BEEN INSPECTED AND FOUND AIRWORTHY BY: (Complete the section only if 14 CFR part 21.1830) apples 14 CFR part 121 CERTIFICATE HOLDER (GiVe CERTIFICATED MECHANIC (Give Certificate No.) CERTIFICATED REPAIR STATION (Give Certicate Certificate No) AIRCRAFT MANUFACTURER (GIve name or tim)
DATE TITLE SIGNATURE (Check ALL applicable block Rems A and B) THE CERTIFICATE REQUESTED V. FAA REPRESENTATIVE CERTIFICATION B. Inspection for a special flight perit under Section VII A. I find that the aircraft described in Section I or VIl meets requirements for was conducted by: FAA INSPECTOR AMENDMENT OR MODIFICATION OF CURRENT AIRWORTHINESS CERTIFICATE FAA DESIGNEE CERTIFICATE HOLDER UNDER 14 CFR part 65 14 CFR part 121 OR 135 14 CFR part 145 DATE MIDO/FSDO FAA INSPECTOR'S SIGNATURE or DESIGNEE'S -AA INSPECTOR S CERTIFICATION FILE REVIEV
OFFICE SIGNATURE AND NO SIGNATURE FAA Form 8130-6 (04-11) All Previous Editions Superseded D-23
Appendix D Figure D-20b. Sample FAA Form 8130-6, Application for U.S. Airworthiness Certificate, Special - Special Flight Permit for Production Flight Testing (Reverse Side) (cont'd) A. MANUFACTURER
NAME ADDRESS VI. PRODUCTION B. PRODUCTION BASIS (Check applicable item) Cessna Aircraft Company 1 Cessna Boulevard, Witchita, KS 67215 V PRODUCTION CERTIFICATE (Give production certificate number) → 123
TYPE CERTIFICATE OTHER:
GIVE QUANTITY OF CERTIFICATES REQUIRED FOR OPERATING NEEDS 10 DATE OF APPLICATION NAME AND TITLE (Print or type, NATU 06/01/2002 Joe Quality, Manager , Chuat A. DESCRIPTION OF AIRCRAFT
REGISTERED OWNER ADDRESS BUILDER (Make) MODEL
SERIAL NUMBER REGISTRATION MARK B. DESCRIPTION OF FLIGHT CUSTOMER DEMONSTRATION FLIGHTS • (Check if applicable) VII. SPECIAL FLIGHT PERMIT PURPOSES OTHER THAN PRODUCTION FLIGHT TEST FROM • TO
VIA DEPARTURE DATE DURATION C. CREW REQUIRED TO OPERATE THE AIRCRAFT AND ITS EQUIPMENT 1 PILOT 1| CO-PILOT FLIGHT ENGINEER OTHER (Spec.fy) D. THE AIRCRAFT DOES NOT MEET THE APPLICABLE AIRWORTHINESS REQUIREMENTS AS FOLLOWS:
(f necessary) F. CERTIFICATION - 1 hereby certify that I i the registered owner (or his agent) of the aircraft described above, that the aircraft is registered with the Federal Aviation Administration in accordance with Title 49 of the Inted States Code 44101 et seg. and applicable Federal Aviation Regulations; and that the aircraft has been inspected and is safe for the flight described.
DATE NAME AND TITLE (Print or fype) SIGNATURE A. Operating Limitations and Markings in Compliance With 14 CFR Section 91.9, G. Statement of Conformity, FAA Form 8130-9 (Aftach when required) DOCUMENTATION (FAA/DESIGNEE As Applicable H. Foreign Airworthiness Certification for Import Aircrat VIII. AIRWORTHINESS B. Current Operating Limitations Attached (Attach when required)
1. Previous Airworthiness Certificate Issued in Accordance With use only C. Data, Drawings, Photographs, etc. (Atfach when required) 14 CFR Section CAR _ (Original attached) D. Current Weight and Balance Information Available in Aircraft E. Major Repair and Alteration, FAA For 337 (Attach when required) J. Current Airworthiness Certificate Issued in Accordance With 14 CFR Section (Copy attached) F. This inspection Recorded in Aircraft Records K. Light-Sport Aircraft Statement of Compliance, FAA Fom 8130-15 (Aftach when required) FAA Form 8130-6 (04-11) All Previous Editions Superseded D-24
Appendix D Figure D-21a. Sample FAA Form 8130-6, Application for U.S. Airworthiness Certificate, Special - Special Flight Permit for Production Flight Testing, Light-Sport Aircraft Manufacturer (Face Side) FAA FORM 8130-6, APPLICATION FOR U.S. AIRWORTHINESS CERTIFICATE Form Approved O.M.B. No. 2120-0018 APPLICATION FOR INSTRUCTIONS - Print or type. Do not write in shaded areas; these are for FAA of Transportation U.S. AIRWORTHINESS use only. Submit original only to an authorized FAA Representative. If additional space is required, use attachment. For special flight permits complete Sections Federal Aviation CERTIFICATE II, VI, and VII as applicable.
Administration REGISTRATION MARK 2. AIRCRAFT BUILDER'S NAME (Make) AIRCRAFT MODEL DESIGNATION 1. YR. MFR FAA CODING AIRCRAFT DESCRIPTION 5. AIRCRAFT SERIAL NO. N1234LS 6. ENGINE BUILDER'S NAME (Make) Acme Company 7. ENGINE MODEL DESIGNATION Pegasus 2010 0007 Rotax 912UL
8. NUMBER OF ENGINES 9. PROPELLER BUILDER'S NAME (Make) 10. PROPELLER MODEL DESIGNATION 11. AIRCRAFT IS (Check if applicable) 1 IVO 3 blade IMPORT APPLICATION IS HEREBY MADE FOR: (Check applicable items) STANDARD AIRWORTHINESS CERTIFICATE (Indicate category) NORMAL UTILITY ACROBATIC TRANSPORT COMMUTER BALLOON OTHER SPECIAL AIRWORTHINESS CERTIFICATE (Check appropriate #ems)
PRIMARY LIGHT-SPORT (nacate Class) Airplane Power-Parachute Weight-Shif-Control Glider - Lighter than Air
LIMITED
PROVISIONAL ( CLASS I
CLASS II II. CERTIFICATION REQUESTED AGRICULTURE AND PEST CONTROL 2 AERIAL SURVEY AERIAL ADVERTISING RESTRICTED (Indicate FOREST (Wildlife conservation) 5 PATROLLING WEATHER CONTROL to de conducted) OTHER (Specity) RESEARCH AND DEVELOPMENT 2 AMATEUR BUILT 3 •EXHIBITION AIR RACING CREW TRAINING 6 MARKET SURVEY TO SHOW COMPLIANCE WITH THE CFR _ OPERATING (Primary Category) KIT BUILT AIRCRAFT 8A Existing aircraft without an airworthiness certificate & do not meet § 103.1 EXPERIMENTAL (Indicate op OPERATING 8B Operating Light-Sport Kit-built LIGHT-SPORT 8C Operating light-sport previously issued special light-sport category airworthines! certificate under § 21.190 UNMANNED 9A RESEARCH AND DEVELOPMENT 9C CREW TRAINING AIRCRAFT 9B MARKET SURVEY
FERRY FLIGHT FOR REPAIRS, ALTERATIONS, MAINTENANCE, OR STORAGE SPECIAL FLIGHT PERMIT pinacate 2 EVACUATE FROM AREA OF IMPENDING DANGER operation to be conducted, then complete Section Vi or VII as applicable on reverse side) 3 OPERATION IN EXCESS OF MAXIMUM CERTIFICATED TAKE-OFF WEIGHT DELIVERING OR EXPORTING 5 / PRODUCTION FLIGHT TESTING
CUSTOMER DEMONSTRATION FLIGHTS MULTIPLE IPLE AIRWORTHINESS (Check ABOVE "Restricted Operation and "Standard" or "Limited" as applicable) A. REGISTERED OWNER (As shown on certificate of aircraft registratiov) IF DEALER, CHECK HERE
NAME ADDRESS B. AIRCRAFT CERTIFICATION locks and complete tems as indicated) III. OWNER'S CERTIFICATION AIRCRAFT SPECIFICATION OR TYPE CERTIFICATE DATA SHEET (GWe No and AIRWORTHINESS DIRECTIVES (Check if all applicable ADs are complied with and gWe the number Revision No. of the last AD SUPPLEMENT available in the biweekly series as of the date of application) AIRCRAFT LISTING (Gre page SUPPLEMENTAL TYPE CERTIFICATE (List number of each STC incorporated)
AIRCRAFT AND MAINTENANCE REC CHECK IF RECORDS IN TOTAL AIRFRAME HOURS EXPERIMENTAL ONLY (Enter hours flown since last certificate issued COMPLIANCE WITH rerence 14 CFR section 91.417 D. CERTIFICATION - T hereby certify that I am the registered owner (or his agent) of the aircraft described above, that the aircraft is registered with the Federal Aviation Administration in accordance with Title 49 of the United States Code 44101 et seg, and applicable Federal Aviation Regulations, and that the aircraft has been inspected and is airworthy and eligible for th airworthiness certificate requested.
DATE OF APPLICATION NAME AND TITLE (Print or type) SIGNATURE IV. INSPECTION VERIFICATION A. THE AIRCRAFT DESCRIBED ABOVE HAS BEEN INSPECTED AND FOUND AIRWORTHY BY: (Complete the section cry if 14 CFR part 21.183(%) applies) 14 CFR part 121 CERTIFICATE HOLDER (Give CERTIFICATED MECHANIC (Give Certificate No.) CERTIFICATED REPAIR STATION (Give Certicate AGENCY Certificate No.) AIRCRAFT MANUFACTURER (GIe name or firm)
DATE TITLE SIGNATURE (Check ALL applicable block lems A and B) THE CERTIFICATE REQUESTED V. FAA REPRESENTATIVE B. Inspection for a special flight permit under Section VII A. I find that the aircraft described in Section I or VIl meets requirements for AMENDMENT OR MODIFICATION OF CURRENT AIRWORTHINESS CERTIFICATE CERTIFICATION was concuced ov FAA INSPECTOR FAA DESIGNEE CERTIFICATE HOLDER UNDER 14 CFR part 65 14 CFR part 121 OR 135 14 CFR part 145 DATE MIDO/FSDO FAA INSPECTOR'S SIGNATURE or DESIGNEE'S FAA INSPECTOR'S CERTIFICATION FILE REVIEW OFFICE SIGNATURE AND NO. SIGNATURE FAA Form 8130-6 (04-11) All Previous Editions Superseded D-25
Appendix D Figure D-21b. Sample FAA Form 8130-6, Application for U.S. Airworthiness Certificate, Special - Special Flight Permit for Production Flight Testing, Light-Sport Aircraft Manufacturer (Reverse Side) (cont'd.)
A MANUFACTURER
NAME ADDRESS VI. PRODUCTION FLIGHT TESTING ACME Co. B. PRODUCTION BASIS (Check applicable item) 420 W Jackson, Mexico, MO 65265 PRODUCTION CERTIFICATE (Give production certificate number)
TYPE CERTIFICATE OTHER:
C. GIVE QUANTITY OF CERTIFICATES REQUIRED FOR OPERATING NEEDS 1 DATE OF APPLICATION JAME AND TITLE (Print or type GNATU Quali 09/01/2010 Joseph Quality, Manager, Q.A песк
A DESCRIPTION OF AIRCRAFT
REGISTERED OWNER ADDRESS BUILDER (Make) MODEL
SERIAL NUMBER REGISTRATION MARK B. DESCRIPTION OF FLIGHT CUSTOMER DEMONSTRATION FLIGHTS • (Check if applicable) VII. SPECIAL FLIGHT PERMIT PURPOSES OTHER THAN PRODUCTION FLIGHT TEST FROM
VIA DEPARTURE DATE DURATION C. CREW REQUIRED TO OPERATE THE AIRCRAFT AND ITS EQUIPMENT _ PILOT • CO-PILOT FLIGHT ENGINEER OTHER (Specty) D. THE AIRCRAFT DOES NOT MEET THE APPLICABLE AIRWORTHINESS REQUIREMENTS AS FOLLOWS:
ent it necessary) F. CERTIFICATION - I hereby certify that I am the registered owner (or his agent) of the aircraft described above, that the aircraft is registered with the Federal Awiation Administration in accordance with Title 49 of the United States Code 44101 et seg. and applicable Federal Aviation Regulations; and that the aircraft has been inspected and is safe for the flight described.
DATE NAME AND TITLE (Print or fype) SIGNATURE A. Operating Limitations and Markings in Compliance With 14 CFR Section 91.9. G. Statement of Conformity, FAA Form 8130-9 (Attach when required) DOCUMENTATION /FAA/DESIGNEE As Applicable
4. Foreign Airworthiness Certification for Import Aircraft VIII. AIRWORTHINESS use onlyi B. Current Operating Limitations Attached C. Data, Drawings, Photographs, etc. (Attach when required) 1. Previous Ainworthiness Certificate Issued in Accordance With 14 CFR Section Attach when required) D. Current Weight and Balance Infomation Available in Aircraft J. Current Airworthiness Certificate Issued in Accordance With E. Major Repair and Alteration, FAA For 337 (Affach when required) F. This inspection Recorded in Aircraft Records K. List-Spot Arat Stalement of Complance, FA Form B8130-15 (Atech 14 CFR Section - (Copy attached) when required) FAA Form 8130-6 (04-11) All Previous Editions Superseded D-26