Appendix D Figure D-22a. Sample FAA Form 8130-6, Application for U.S. Airworthiness Certificate, Special - Special Flight Permit for Production Flight Testing, Unmanned 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 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 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 TPЕ33-10T
8. NUMBER OF ENGINES 9. PROPELLER BUILDER'S NAME (Make) 10. PROPELLER MODEL DESIGNATION 11. AIRCRAFT IS (Check / applicable) McCauley Propeller Systems 3GFR36C606-B 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 (Indicate Class) Airplane Power-Parachute Weight-Shift-Control Glider Lighter than Air
LIMITED PROVISIONAL (Indicate ciss) CLASS I
CLASS II II. CERTIFICATION REQUESTED AGRICULTURE AND PEST CONTROL 2 AERIAL SURVEY | 3 AERIAL ADVERTISING 3 RESTRICTED (Indic to be conducted) FOREST (Widlife 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 of to be conducted) OPERATING 8A 8B Existing aircraft without an airworthiness certificate & do not meet § 103.1 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 (Indicate 2 EVACUATE FROM AREA OF IMPENDING DANGER Section VI or Vill as appicable on reverse side) OPERATION IN EXCESS OF MAXIMUM CERTIFICATED TAKE-OFF WEIGHT DELIVERING OR EXPORTING 5V PRODUCTION FLIGHT TESTING
CUSTOMER DEMONSTRATION FLIGHTS MULTIPLE AIRWORTHINESS CERTIFICATE (Check ABOVE "Restricted Operation? and "Standard" or "Limited" as applicable) A REG OWNER (As shown on certificate of at craft registratiovy) IF DEALER, CHECK HERE
NAME ADDRESS III. OWNER'S CERTIFICATION B. AIRCRAFT CERTIFICATION B AIRCRAFT SPECIFICATION OR TYPE CERTIFICATE DATA SHEET (Give No and blocks and complete tems as indicated) AIRWORTHINESS DIRECTIVES CRecK Ta am. cable ADs are complied with and give the numbe Revision No. of the 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)
AIRCRAFT OPERATION AND MAINTENANCE RECORDS CHECK IF RECORDS IN TOTAL AIRFRAME HOURS EXPERIMENTAL ONLY (Enter hours flown since lst certificate issued
COMPLIANCE WITH 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 the airworthiness certificate requested.
DATE OF APPLICATION NAME AND TITLE (Print or type) SIGNATURE A THE AIRCRAFT DESCRIBED ABOVE HAS BEEN INSPECTED AND FOUND AIRWORTHY BY: (Complete the section only if 14 CFR part 21.1830) applies) IV. INSPECTION VERIFICATION Certificate No.) 14 CFR part 121 CERTIFICATE HOLDER (Give CERTIFICATED MECHANIC (Give Certiticate No.) CERTIFICATED REPAIR STATION (GiVe Certicate AIRCRAFT MANUFACTURER (GNe name or tim)
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 aircrat 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-27
Appendix D Figure D-22b. Sample FAA Form 8130-6, Application for U.S. Airworthiness Certificate, Special - Special Flight Permit for Production Flight Testing, Unmanned Aircraft Manufacturer (Reverse Side) (cont'd.)
A MANUFACTURER
NAME ADDRESS VI. PRODUCTION FLIGHT TESTING General Atomics Corp. B. PRODUCTION BASIS (Check applicable item) P.O Box 138, San Diego, CA 90804 PRODUCTION CERTIFICATE (Give production certificate number)
TYPE CERTIFICATE OTHER:
C. GIVE QUANTITY OF CERTIFICATES REQUIRED FOR OPERATING NEEDS 1 12/15/2010CATION NAME AND TITLE (Print or type) R.L. Brown, Operations Manager
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 | PILOT | CO-PILOT FLIGHT ENGINEER OTHER (Specy) D. THE AIRCRAFT DOES NOT MEET THE APPLICABLE AIRWORTHINESS REQUIREMENTS AS FOLLOWS:
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 int or type) SIGNATURE A. Operating Limitations and Markings in Compliance With 14 CFR Section 91.9. ©. Statement of Conformity, FAA Form 8130-9 (Attach when required) DOCUMENTATION /FAA/DESIGNER As Applicable H. Foreign Airworthiness Certification for Import Aircraft VIII. AIRWORTHINESS B. Current Operating Limitations Attached (Aftach 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 affached) 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 Re ded 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-28
Appendix D Figure D-23. Sample FAA Form 8130-6, Application for U.S. Airworthiness Certificate, Multiple (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
1. REGISTRATION MARK 2. AIRCRAFT BUILDER'S NAME (Make) 3. AIRCRAFT MODEL DESIGNATION 4. YR. MFR FAA CODING N54321 Piper Aircraft Company PA18A-150 1951
5. AIRCRAFT SERIAL NO. 6. ENGINE BUILDER'S NAME (Make) 7. ENGINE MODEL DESIGNATION 18-3792 Lycoming Engines 0-320
8. NUMBER OF ENGINES 9. PROPELLER BUILDER'S NAME (Make) 10. PROPELLER MODEL DESIGNATION 11. AIRCRAFT IS (Check if applicable) Sensenich Propeller M74DM IMPORT APPLICATION IS HEREBY MADE FOR: (Check applicable items) STANDARD AIRWORTHINESS CERTIFICATE (Indicate category) ACROBATIC COMMUTER BALLOON OTHER | SPECIAL AIRWORTHINESS CERTIFICATE (Check appropriate Rems)
PRIMARY LIGHT-SPORT (nacate 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 2 V AERIAL SURVEY AERIAL ADVERTISING RESTRICTED (Indicate operations) to be conducted) FOREST (Wildlife conservation) PATROLLING WEATHER CONTROL OTHER (Specity) RESEARCH AND DEVELOPMENT 12 | | AMATEUR BUILT 3 EXHIBITION AIR RACING CREW TRAINING 6 MARKET SURVEY TO SHOW COMPLIANCE WITH THE CFR 7 OPERATING (Primary Category) KIT BUILT AIRCRAFT Existing aircraft without an airworthiness certificate & do not meet § 103.1 EXPERIMENTAL (Indicate operations) 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 pinacate EVACUATE FROM AREA OF IMPENDING DANGER 8 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 CB V 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 North Central Airplane Corp. 1 Box 502 Cutback, MN, 43692 B. AIRCRAFT CERTIFICATION BASIS (Check applicable blocks and co III. OWNER'S CERTIFICATION AIRCRAFT SPECIFICATION OR TYPE CERTIFICATE DATA SHEET (Give No and AIRWORTHINESS DIRECTIVES (Check if all applicable ADS are co lied with and give the number Revision No) 1A2 Rev. 33, AR-7 Rev. 9 2009-23 SUPPLEMENT available in the biweekly series as of the date of application AIRCRAFT LISTING (Give page number(s)) SUPPLEMENTAL TYPE CERTIFICATE (List number of each STC Incorporated) 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 12050 or renewed 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 th airworthiness certificate requested.
DATE OF APPLICATION NAME AND TITLE (Print or type SIGNATURE 11/21/2009 John Jones, President Jaken Ganes A. THE AIRCRAFT DESCRIBED ABOVE HAS BEEN INSPECTED AND FOUND AIRWORTHY BY: (Complete the section only if 14 CFR part 21.183(%) apples) IV. INSPECTION VERIFICATION 14 CFR part 121 CERTIFICATE HOLDER (Give CERTIFICATED MECHANIC (Give Certificate No.) CERTIFICATED REPAIR STATION (GiNe Certicate AGENCY AIRCRAFT MANUFACTURER (Give name or firm)
DATE TITLE SIGNATURE (Check ALL applicable block tems A and B) THE CERTIFICATE REQUESTED V. FAA REPRESENTATIVE A. I find that the aircraft described in Section I or VIl meets requirements for AMENDMENT OR MODIFICATION OF CURRENT AIRWORTHINESS CERTIFICATE B. Inspection for a special flight perit under Section VII CERTIFICATION was conqucted 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 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-29