STC SA291SW

< 1 FEDERAL AVIATION AGENCY

1. NAME AND ADDRESS OF APPLICANT CHARLES 9. FKDBL

AIRCRAFT PARTS 6037 CAMEION BLVD.

WE» ORLEANS 22, LA.

FORM APPROVED, BUDGET BUREAU NO. 04-R015

INSTRUCTIONS - SUBMIT IN TRI PLICATE TO LOCAL FAA FLISHT STANDARDS INSPECTOR.

COPY WILL BE RETURNED TO APPLICANT UPON 1 S3 U A N C E

2. SUPPLEMENTAL TYPE CERTIFICATE APPLIED FOR:

rn FLOAT rn _1 J MUBMBtT 1 __ | ENGINE | __ | PROPELLER

ORIGINAL MODEL DESIGNATION KM 89*2000 NEW MODEL DESIGNATION (If detlrtd) NONE 3- DESCRIPTION OF CHANGE RBVISED COVER PLATES «* WOWING X B*BtD 10'1/63' »%. WILL DATA BE AVAILABLE FOR SALE OR RELEASE TO

b. WILL PARTS BE MANUFACTURED FOR SALE (Ktt. CAR

5. SIGNATURE AND TITLE OF APPLICANT * "^VJSTr'oF APPLICATION OTHER PERSONS? C] YES Q NO

l.SS)1 CH YES [~~1 NO ^9/^' / /^_^rvy x?7x —— -X^-xC'C-Z^<— ~*-**— ^c — ^ — t^^-^t-Cr

SIGNATURE TITLE

6. To be Completed by FAA

NATURE AND LOCATION OF DATA DATA LISTSU IN IBM 3 ABOVE ON FBLE RlfBMHCi MBJ1CT Z417SWS.

APPLICAHJI U08LATIOTS CAR IS.

ORIGINAL TYPE CERTIFICATE HO. FAA AR 173 -'.EMENTAL TYPE CERTIFICATE MO. / F~- SA291SM / DATE OF APPROVAL /7&t~Hi, / atU/ZO/63 AT Sy-210.

=>ROVAL

SIGNATURE

H SLADGBTB

UF, EHGIHSBRIMG & MMJUFACTUHDK BHMCU TITLE FAA AC 6! 42Q7 FORM FAA-2417 {5-59}