TEAR OFF DEPARTMENT OF TRANSPORTATION

BEFORE USING FEDERAL AVIATION ADMINISTRATION

SUPPLEMENTAL

INFORMATION

CERTIFICATION OF WAIVER OR AUTHORIZATION APPLICATION - PRIVACY ACT

The information on the accompanying form is solicited under authority of Federal Aviation Regulations

Parts 91, 101, and 105.

Submission of the information is mandatory. 

The purpose of this information is to establish eligibility for certificate of waiver or authorization 

The data will be used for recordkeeping and statistical purposes. 

Incomplete submission may result in delay or denial of your request.

FAA Form 7711-2 (8-08) Supersedes Previous Edition

DETACH THIS PART BEFORE USING
 

 From Approved: O.M.B. No.2120-0027 08/31/2008

 APPLICANTS - DO NOT USE THESE SPACES

Action

□ Approved □ Disapproved – ”Explain under "Remarks"

Signature of authorized FAA representative

8. Area of operation (Location, altitudes, etc.)

9a. Beginning (Date and hour) b. Ending (Date and hour)

10. Aircraft

make and model

(a)

Pilot's Name

(b)

Certificate number 

and rating

(c)

 Home address

 (Street, City, State) (d)

 

 

 

 

 

 

 

No certificate may be issued unless a completed application

form has been received (14 C.F.R. 91. 101. and 105).

US Department of Transportation

Federal Aviation Administration Region Date

 APPLICATION FOR 

CERTIFICATE OF WAIVER

OR AUTHORIZATION

INSTRUCTIONS

Submit this application in triplicate (3) to any FAA Flight 

Standards district office.

Applicants requesting a Certificate of Waiver or Authorization for an aviation event must complete all the applicable 

items on this form and attach a properly marked 7.5 series 

Topographic Quadrangle Map(s), published by the U.S. 

Geological Survey (scale 1:24,000), of the proposed operating area. The map(s) must include scale depictions of the 

flightlines, showlines, race courses, and the location of the 

air event control point, Police dispatch, ambulance, and fire

fighting equipment. The applicant may also wish to submit 

photographs and scale diagrams as supplemental material 

to assist in the FAA's evaluation of a particular site. 

Application for a Certificate of Waiver or Authorization must 

be submitted 45 days prior to the requested date of the 

event.

Applicants requesting a Certificate of Waiver or Authorization for activities other than an aviation event will complete 

items 1 through 10 only and the certification, item 17, on the 

reverse.

1. Name of organization 2. Name of responsible person

3. Permanent House number and street or route number City State and ZIP code Telephone No.

mailing

address

 6. FAR section and number to be waived

.

 7. Detailed description of proposed operation (Attach supplement if needed)

FAA Form 7711 -2 (8-08) Supersedes Previous Edition

4. State whether the applicant or any of its principal officers/owners has an application for waiver pending at any other office of the FAA. 

 5. State whether the applicant or any of its principal officers owners has ever had its application for waiver denied, or whether the FAA has ever withdrawn a waiver from the applicant or any of its 

 principal officers/owners.

Laminated Pictures Matthew Herrier

373 Wapello Street Altadena California, 91001 (310)749-1797

Yes, there is a waiver application pending.

No.

Sections 61.113(a)&(b), 91.7(a), 91.121, 91.151(b), 91.405(a), 91.407(a)(1), 91.409(a)(1)&(a)(2), 91.417(a)&(b).

Operation of a DJI Inspire 1 UAV under FMRA Section 333 for the purpose of filming. Aircraft will operate at or below 500ft AGL at all times, unless 

special request is approved by by ATC. UAV will be operated within visual line of sight of the pilot in command (PIC) at all times. A dedicated safety 

observer will be used in all operations, maintaining verbal communication with PIC. PIC will inspect the UAV and ground control station prior to 

each flight, to ensure safe operation. Typical operation includes 2 operators, the PIC and a camera gimbal operator, both using radio-control. 

Permission to operate will be obtained by Laminated Pictures, LLC, or by the production.

Including but not limited to the United States, including Alaska and Hawaii. Altitude reamins below 500ft AGL, unless approved by ATC.

11/10/2015 12:00:00

DJI Inspire 1 Matthew Herrier 373 Wapello St. 

Altadena, CA 91001

DJI Inspire 1 Jeff Moriarty 32109 Corte Carmela 

Temecula, CA 92592
 

ITEMS 11 THROUGH 16 TO BE FILLED OUT FOR AIR SHOW/AIR RACE WAIVER REQUESTS ONLY.

11. The air event will be sponsored by:

If sufficient space is not available, the entire schedule of events may be submitted on separate sheets, in the order and manner indicated above.

 The undersigned applicant accepts full responsibility for the strict observance of the terms of the Certificate 

Please Read of Waiver or Authorization, and understands that the authorization contained in such certificate will be strictly 

 limited to the above described operation. 

17. Certification - I CERTIFY that the foregoing statements are true.

□ Physician

□ Ambulance

□ Fire truck

□ Crash wagon

□ Other - Specify

12. Permanent House number and street or route number City State and ZIP code Telephone No.

mailing

address

13. Policing (Describe provisions to be made for policing the event.)

14. Emergency facilities (Mark all that will be available at time and place of air event.)

15. Air Traffic control (Describe method of controlling traffic, including provision for arrival and departure of scheduled aircraft.)

16. Schedule of Events (include arrival and departure of scheduled aircraft and other periods the airport maybe open.)

Hour Date Event

(a) (b) (c)

Date Signature of Applicant

Remarks

FAA Form 7711-2 (8-08) Supersedes Previous Edition

11/10/2015