To: DAR

 

In accordance with 14CFR §21.193, I request a Special airworthiness for my aircraft for the purpose of operating Experimental Light-Sport Aircraft, Kit built.  The aircraft description is as follows:

 

Builder’s Name (Make):________________________________ Number: N ________

 

Model:  ______________________________Serial Number:_________________

 

No of Engines: _1 __    No. of Seats: ___

 

YES  NO      I enclosed FAA For 8130-6, Application for Airworthiness Certificate, with Section I,  II, and III complete

(X  )  (    )

 

YES  NO    I possess AC Form 8050-3, Certification of Aircraft Registration. Or appropriate Pink copy of 8050-1.

( X )  (    )

 

YES  NO    I enclosed a drawing or photographs of the aircraft.

(  X )  (    )

 

YES  NO    The aircraft has been weighed the most forward and aft center of gravity positions are within the

( X  )  (    )    established limits.  A copy of the weight and loading report is included with this letter.

 

YES  NO     The marking requirements of 14 CFR § 45 have been complied with; including permanent attachment of a

 ( X  )  (    )    fireproof identification (data) plate, permanent applications of appropriate registration marks and the word

                    “EXPERIMENTAL” displayed near each entrance.

 

YES  NO     The following placard is displayed in the cockpit in full view of all occupants (not required for single place

 ( X  )  (    )     aircraft):

“PASSENGER WARNING – THIS AIRCRAFT IS EXPERIMENTAL LIGHT-SPORT AIRCRAFT AND DOES NOT COMPLY WITH FEDERAL SAFETY REGULATIONS FOR STANDARD AIRCRAFT”

 

YES  NO       The instruments and equipment listed in 14 CFR § 91.205 have been installed, appropriate to the operations

 ( X   )  (    )      which I intend to conduct.  I intend to conduct VFR Day Operations

 

YES  NO    Instruments range marking and other applicable operating limitations have been installed as required by 14 CFR §

( X   )  (    )     91.9

 

YES  NO    An Emergency Locator Transmitter (ELT) has been installed, if required, per 14 CFR § 91.207 (An ELT is not required for PPCs or WSC)

(    )  ( X   )

 

YES  NO    The powerplant installation has undergone at least one hour of ground operation at various speeds from idle to full

 (  X  )  (    )    power to determine and ensure that all systems are operating properly. 

                THE TIME ASSOCIATED WITH GROUND OPERATIONS HAS BEEN RECORDED AS A LOGBOOK ENTRY.

 

YES  NO   This aircraft as a Type Certificated (TC) engine/propeller combination?

(    )  ( X   )   If yes, please list what aircraft (s) the approved combination is normally found on below?            

                    TC aircraft, engine, and/or propeller combination data:______________________

 

YES  NO    All applicable Airworthiness Directives (AD’s) for engine, propeller or appliances been complied with?

( X   )  (    )

 

YES  NO    THE FOLLOWING STATEMENT OF SIMILARLY WORDED STATEMENT HAS BEEN RECORDED and

( X   )  (    )   SIGNED, IN THE AIRCRAFT LOGBOOK, “I certify that this aircraft has been inspected (insert date) in

                   accordance with the scope and detail of 14 CFR Part 43, appendix D and found to be in a condition for safe

                   operation.”

 

********This aircraft will be available for inspection at the location noted, and directions are as follows:

Address: ______________________________________________________________________

 

Directions: ____________________________________________________________________

 

I request airworthiness certification and operating limitations be issued permitting me to operate the aircraft within the following geographical area for flight testing.  My initial flights will determine engine reliability and flight control characteristics. 

 

Within a 25 mile radius of my base airport which is _____________________________ designator _______

 

My residence telephone number is:  ( _________________________  )  

 

My daytime business telephone number is: (  _______________________ )

  

SIGNED:  ____ __________________________________________Owner