No cortin cote mny bo Issued unless n complotod appllcaUon 

form has been rocelved (14 C .. F R '"' 91 101 and 10 5) 

0 From Approved: O.M.B. No.2120-0027 0813112008 

US De partment of Transportation APPUCANTS ·DO NOT USE THESE SPACES 

Federal Aviation A dministration Region I Oato 

APPLICATION FOR Action 

O Approved 0 Disapproved- ·explain under "Remarks" 

CERTIFICATE OF WAIVER Slgnaturo of authorized FAA ropreaontatlve 

OR AUTHORIZATION 

INSTRUCTIONS 

Submit this application in triplicate (3) to any FAA Flight lighting equipmenl The applicant may also wish to submit 

Standards district offic.e. photographs and scale diagrams as supplemental material 

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

Applicants requesting a Certificate of Waiver or Authoriza- Application for a Certificate of Waiver or Authorization must 

lion for an aviation event must complete all the applicable be submitted 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. 

Geological Survey (scale 1 :24,000). of the proposed operat- Applicants requesting a Certificate of Waiver or Authorizelng area. The map(s) must Include scale depictions of the lion for activities other than an aviation event will complete 

nlghllines. showfines, race courses, and the location of the items 1 through 10 only and the certification, item 17, on the 

air event control point, Pollee dispatch, ambulance, and fire reverse. 

I. Name ol organization 2. Name ol respoMible person 

Due North Productions Mark Smith 

3. Permanent House number and stroot or roulo number City State and ZJP codo Telephono No. mailing 

&ddmss 2204 Eucild St Santa Moinca 90405 3102130790 

4. Sl8to wllother the applicant or any ollta P<lncoP!II offiCOI'Iiawnors has nn applleatlon lot Wlllvor pending ut any othor offta:~ of tho FAA. 

SAMPLE 

5. Sl8to wllothor tho applicant or any of it.s P<lndpat Offleo<$ ownc,. hu over h.,d Ita application lor walvor doniod. or wlloUtor tho FAA has ovor Witfldmwn o walvor from the app6cant or any ot lt.s 

f)MCIIlel clfic8ls/CMlle<$. 

NONE 

6. FAR section and number to be waived 

TBD 

7. Detailed desaiption ol proposod operation (Ansch svpplement if need«J) 

SAMPLE 

8. Area or operauon (LocatiOn. altitUdes, etc.} 

SAMPLE 

9a. Beginning (Dale and hourj b. Endng (Date and hout1 

10. Aitttaft Pllol's Name Cortmca10 number Home address 

make 'Ia: model andmmg (b) (Stroo\~· Stale) (c) 

OJI 450 Flarnev>Mel MM< Smth NS56GC 2204 EUClid St. SMO, CA 90405 

FAA Form 7711 -2 (8-00)Su~sPr!MousEdillon 
.... ITEMS 11 THROUGH 16 TO BE FILLED OUT FOR AIR SHOW/AIR RACE WAIVER REQUESTS ONLY. 

11 . The air event will be sponsored by: 

12. Pennanent House number and street or route number mailing 

address 

City State and ZIP code Telephone No. 

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

14. Emergency facilities (Marl< aN that win be available at time and place of airovent.) 

0 Physician 0 Fire truck 0 Other - Specify 

O Ambulance 0 Crash wagon 

15. /lJr Traffic conuol (Describe method of controlling traffic, incJuding provision for arrival and depatturn of sdleduJfld aircraft} 

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

Hour Date Event 

(a) (b) (c) 

If suffiCient space is not available, the entim schedule of events may be submitted on sepamte sheets. in tho order and manner indicated above. 

PleaseRe? 

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

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

limited to the above described operation. 

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

0111112015 

Date Signature of Applicant 

~ Shtd:J£ 

Remarks 

THIS IS A SAMPLE 

FAA Fonn n11-2 (8-08) Supersedes Previous Edition