No certificate may be issued unless a completed applicat i on form has been received (14 C F R 91 101 and 105) 

## ... 

# 0 From Approved: O . M.B. No .21 20-0027 08/3 1 /2008 

## US Department of Transportation APPLICANTS - DO NOT USE THESE SPACES 

### Federal Aviation Administration Region 1 Date 

# APPLICATION FOR Action O Approved 

# 0 Disapproved - "Ex plain under "Remarks" 

# CERTIFICATE OF WAIVER Signature of authoriz e d FAA repre se ntative 

# OR AUTHORIZATION INSTRUCTIONS Submit th is application in triplicate (3) to any FAA Flight fighting equipmen t. The applicant may also wish to submit Standards district office. photographs and scale d i agrams as su pplem ental material to assist in the FAA 's eva lu ation of a pa rtic ular site. Applicants requesting a Ce rtificate o f Waiver or Authoriza- App l ication for a Ce rtifica te o f Waiver or Autho rization must lion for an aviation event must compl ete all the applicable be s ubmitted 45 days prior to the requested date of the items on this form and attach a properly marked 

### 7.5 series event. Topographic Quadrangle Map(s), published by the U.S. Geolo gical Survey (sca l e 

### 1 : 24,000), of th e proposed opera!- Applicants reque s tin g a Certificate of Wa iver or Au th oriza in g area. Th e map(s) must include sca l e depictions of the lion for activities o th er than an aviation event will complete flightlines, showlines, race co urses , and the location of the items 

### 1 through 

### 10 only and the certificat io n , item 

### 17, on the air event control point, Po l ice dispatch , ambulance , and fire reverse. 1 . Name of organizat ion 2. Name of responsible pe r son 

## DA V ID L SLACK- AERIAL PHOTOGRAPH Y DA VID L SLACK 3. Penmanent House number and street or route number City State and ZIP code Telephone No .

mailing 

### 17076 BIRDS EYE DR PERR IS CA 

### 92570 9493946457 address 4 . State whether the applicant or any of its ptinetpal officers/owners has an application for waiver pending at any other office of the FAA .

NO 5 . State whether the applicant or any of its principal officers owners has ever had its application for waiver denied, or whether the F AA has eve r withdrawn awaiver f romthe ap pl icant or an y of its principal officers/owners. NO 6. FAR section and number to be waived 

## 14 C.F.R. 91 . 119 ( B) AND (C) 7. Detailed description of proposed operation (Attach supplement ifneeded)

CLOSED - SET AER IAL FILMING 

### & PHOTOGRAPHY FOR THE MOTI ON PICTUR E F I LM 

### & TELEVIS ION IN DUSTRIES . 8. Area of operation (Location, altitudes, etc.) UNITED STATES O F AMERICA AND ITS TERRITORIES 9a . Beginning 

### (Date and hour) b . tna1ng 

### (Date ana hour) 

## 06/01/2015 01:00:00 06/01/2017 01:00:00 10 . Aircraft Pilot's Name Certificate number Home address make

**a(~~** model and rating

**(Street, ~\~** 

**.** State) ( b) (c) DJI PHANTOM 3 DAVID SLACK NA 170 7 6 BIRDS EYE DR, PERRIS , CA DJI IN SPIRE 1 DAVID SLACK NA 17076 BIRDS EYE DR, PERRIS , CA DJI 5900/1 000 + A2 DAVID SlACK NA 17076 BIRD S EYE DR. PERRIS. CA

FAA Form 

### 7711 -2 (8-08) Supersedes Previous Edition

# .... ITEMS 11 THROUGH 1 6 TO BE FILLED OUT FOR AIR S HOW / AI

R RACE W A IVER REQU E ST S ONL Y. 11 . The air even t will be sponsored by : 12 . Permanent House number and street or rout e number maili n g City State and Z I P code Te lep hone No. add r ess 13 . Policing (Describe provisions to be made forpolicing the event . )

1 4. E mergenc y facilit ies (Marl< all tha t will be avail able at lime and place of air event.) 

## D Physi cian 

## 0 Fire truck 

## 0 Other - Specify 

## D Ambulance 

## D C rash wagon 15 . Air Traffic control (Describe method ofcontrolling traffic, including provision for arrival and departure ofsched uled aircraft.)

16 . Sc h edu l e of Events (include arrival and departure ofscheduled aircraft and otherperiods the airport maybe open.) Ho u r Date Event (a) (b) (c)

Ifsufficient space is not available, the entire schedule ofevents may 

### be submitted on separate sheets, in the order and mannerindica t ed above. PleaseRe? T he unde rsigned applicant accepts full responsibility for the strict observance of the terms of the Certificate of Waiver o r Authorization , and understands that the authoriz a t ion cont ained in such certificate will be strict l y limited to the above described operati on. 17. Certi ficati on- 1CERTIFY t h at t h e foregoing statements are true. Dat e



## Signatu **~~** 05/16/2015 Rema<Ks



### FAA Form 7711 -2 (8-08) Supersedes Pr evio us Edition