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 of Transportation 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 of authorized 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 of Waiver or Authorizato assist in the FAA's evaluation of a particular site. 

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 opera!- Applicants requesting a Certificate of Waiver 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 whether the applicant or any of its principal 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or any of its principal officers owners has ever had its application for waiver denied, or whether the FAA has ever withdrawn a waiver from the applicant or any of its 

No principal officers/owners. 

6. FAR section and number to 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 and hour) 

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 above 
II"'" lll::M~ 11 I HNUU<:iH 7 o I U J;;l:: J-ILLI::U UU I 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 for policing the event.) 

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

0 Physician 0 Fire truck D Other- Specify 

0Ambulance D Crash wagon 

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) 

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

PleaseRe? 

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

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. 

Date Signature of Applicant 

<J-(~o/ts· ~ ~ it. 4~~ 

Remarks 

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