N o co rt in co t e mn y b o I ss u ed u n l ess n co mp lo t od app ll ca Uo n f orm has been roc e l ved (14 C F R 91 10 1 and 1 0 5 ) 

# .. '"' 

# 0 From Approved: O. M .B. N o.2120-00 27 0813112008 U S D e partm e nt of Transportation APPUCANTS 

### ·DO NOT USE TH ES E SPACES F edera l Aviation A dmi ni s tration Region 

# I Oato 

## A PP LI CAT I ON FO R Action O Approved 

# 0 D i sap p roved- ·explain under "Rem arks " 

## C E RT I F I CATE OF WA I VER Slgna tu ro o f auth o rized FAA ropreaon ta tlv e 

## OR A U THORIZATION I N STR U C TI ONS Submit this application i n triplica t e 

### (3) to 

### any FAA Flight lighting equipmenl The applicant 

### may also wish t o submit Standards dis t rict offic. e. photographs and scale diagrams as supplemental material to assist in the FAA's evaluation of a particular site. Applicants requesting a Certifica te of Waiver 

### or Authoriza- Application 

### for a Certificate of Waiver 

### or Authorization must lion for an aviati o n event must complet e all the applicable be submitted 

### 4 5 days prior to the requested date of the Items on this f o rm an d attach a properl y mark ed 

### 7. 5 series event. Topographic Q ua dra n gle Map(s), published by the U .S. Geo l og i ca l S urvey ( sca l e 

### 1 :24, 000 ). o f th e pro posed op e ra t- A pp lica n t s r eq u esting a C e rt ifica t e of Wai v e r or A uthori zelng a r ea. The ma p ( s ) must I n c lud e sca l e de pictions of th e li o n for activi ties other th a n a n a vi ati o n ev e nt will complete nlghllines. showf in es, race courses, and the location of t he items 

### 1 through 

### 10 only and the certifica tion, item 

### 17 , on the air eve n t co n trol po int , P ollee dispatch, a m bula n ce, an d fi re reverse. I . Name ol organization 2 . Name ol respoMible person 

## D u e Nort h P roduct ions M a rk Sm ith 3 . Permanent House number and stroot or roulo number City State and ZJP codo Telephono No .

mailing 

### 2204 Eucild S t Santa Moi nca 

### 90405 3 1 02130790 &ddmss 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,. h u over h.,d Ita application lor walvo r doniod. or wlloUto r tho FAA has ovor Witfldmwn o walvor from the app6cant or any ot lt.s

f)MCIIlel clfic8ls/CMlle<$ . NO N E 6 . FAR secti on and number to be waived 

## T B D 7. Detailed desaiption ol proposod operation (Ansch svpplemen t ifneed«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

**(Stroo\~·** Stale) (b) (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 even t will be sponsored by: 12 . Pennanent House number and street o r route numb er mailing address City State and ZIP code 

### T elephone No . 

### 13. Policing (DesCiibe provisions t o be 

### made for

### policing the event)



### 14 . Emergency facilitie s (Marl< aN that win be available at t ime andplace ofairo v en t

.) 

## 0 Phys icia n 

## 0 Fire truck 

## 0 Other - Specify O Ambulance 

## 0 Crash wagon 15. /lJr Traffic conuol (Describe method ofcontrolling traffic, incJuding

### provision for arrivaland depatturn of sdleduJfld aircraft}



### 16 . Sched ul e of 

### Events (includ e arrival and departurn ofscheduiiXI aircraft and other periods 

### the airport maybe open. ) Hour Date 

### Event (a) (b) 

### (c)

If

suffiCient space 

### is not ava i lable, the ent im schedule ofevents 

### may be submitted on sepamte sheets. in tho order and manner indicated a bove. 

### P le aseRe? The und e rsigned applicant accepts full responsibility for the strict observan ce or the terms of the Certificate of Wa ive r or Autho rizatio n, and und erstands that the authorization contained in such certincate will be strictly limited to the above described operation . 

### 17 . Certificatio n - I CERTIFY that the foregoing statements are true . D

a te 

### Sig na ture of 

### Applica nt

# ~ 0111112015 

# Shtd:J£ Rema rks 

### THIS IS A SAMPLE

FAA Fonn 

### n11-2 (8-08) 

### Su persedes Previous Edition