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

## ... From Approved: 

### O.M.B. No.2120-0027 08/31/2008 

### US Department ofTransportation APPLICANTS· DO NOT USE THESE SPACES 

### Federal Aviation Administration Region 

# I Date 

## APPLICATION FOR Action OApproved 

# D Disapproved - "Explain under "Remarks" 

## CERTIFICATE OF WAIVER Signature ofauthorized FAA representative 

## OR AUTHORIZATION INSTRUCTIONS Submit this application in triplicate (3) to any FAA Flight fighting equipment. The applicant may also wish to submit Standards district office. photographs and scale diagrams as supplemental material Applicants requesting a Certificate ofWaiver or Authorizato assist in the FAA's evaluation of a particular site. Application for a Certificate ofWaiver or Authorization must lion for an aviation event must complete all the applicable be submitted 45 days prior to the requested date ofthe 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), ofthe proposed opera!- Applicants requesting a Certificate ofWaiver or Authorizaing area. The map(s) must include scale depictions of the lion for activities other than an aviation event will complete flightlines, showlines, race courses, and the location of the items 1 through 10 only and the certification, item 17, on the air event control point, Police dispatch, ambulance, and fire reverse. 1. Name of organization 2. Name of responsible person 

### UAS Maui William Kaunoa Ah Chan 3. Permanent House number and street or route number City State and ZIP code Telephone No.

mailing 746 Hana Hwy Paia Hawaii 96779 (808)463-8238 address 4. State whetherthe applicant or any of its principal officers/owners has an application forwaiver pending at any other office ofthe FAA. No 5. Statewhetherthe applicant orany of its principal officers owners has everhad its application forwaiverdenied, orwhether the FAA has everwithdrawn awaiverfrom the applicant orany of its Noprincipal officers/owners.
6. FAR section and numberto be waived 

### 14 CFR Part 21, 45.23(b), 61.113(a)&(b), 91.7(a), 91.9(b)(2), 91.1 09(a), 91.119, 91.121, 91.151 (a)&(b), 91.203(a)&(b), 91.205(b), 91.405(a), 91.407(a)(1 ), 91.409(a)(1 )&(2), 91.417(a)&(b)



### b8rY!tffi!~?c1gf<(fW~Pa\fliR~ **~?M~RPafiartiw,f{Wac~eWgp(J&h~8fd @rtJ~erfklow**  400AGL in airspace other than B, 

## c and D. This UAV will be below 55lbs and will always be operated within visual line of sight of the pilot and have a trained visual observer to assure safe operations. The operations will be flight instruction, photography/video, aerial survey, site mapping, research to develop economic platforms for law enforcement, search&rescue and disaster relief.

8. Area of operation (Location, altitudes, etc.) State of Hawaii 9a. Beginning (Date and hour) b. Ending (Date andhour) 

### 04-30-2015 OOOOHST 04-30-2016 OOOOHST 10. Aircraft Pilot's Name Certificate number Home address make and model and rating (Street,

**~~!ty,** State) (a) (b) (c) DJI Phantom 11 William Kaunoa Ah Chan 575942044 Private 746 Hana Hwy, Paia, HI 96779 Cheerson CX20 same as above same as above same as above Yuneec 0500 same as above same as above same as aboveII"'"**lll::M~** 11 I HNUU<:iH 7

### o I U J;;l:: J-ILLI::U UUI rUN AIN**~HUW/AIN** NA(.;l:: WAIVI::N Nl::QUI:::S I :S UNL Y. 11. The air event will be sponsored by:

12. Permanent House number and street or route number mailing City State and ZIP code Telephone No. address 13. Policing (Describe provisions to be made forpolicing the event.)

·14. Emergency facilities (Mark all that will be available at time andplace ofairevent.) 

## 0 Physician 

# 0 Fire truck 

# D Other- Specify 0Ambulance 

# D Crash wagon 15. Air Traffic control (Describe method ofcontrolling traffic, includingprovision forarrivaland departure ofscheduledaircraft.)

16. Schedule of Events (include arrival and departure ofscheduledaircraftandotherperiods the airportmaybe open.) Hour Date Event (a) (b) (c)

Ifsufficientspace is notavailable, the entire schedule ofevents maybe submitted on separate sheets, in the orderandmannerindicatedabove. PleaseRe? The undersigned applicant accepts full responsibility for the strict observance ofthe terms ofthe Certificate ofWaiver 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. Date Signature ofApplicant 

# it.**<J-(~o/ts· ~** 

# 4~~**~** Remarks



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