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Date:___________________
C/o
DAR
To:
In accordance with 14CFR §21.193, I request a Special airworthiness for my aircraft for the purpose of operating Experimental Light-Sport Aircraft. The aircraft description is as follows:
Builder’s Name (Make):_--------------------------------- Number: -____________
Model: ______________________________Serial Number:_________________
No of Engines: _1 __ No. of Seats: _2__
YES NO I enclosed FAA For 8130-6, Application for Airworthiness Certificate, with Section I, II, and III complete
( ) ( )
YES NO I possess AC Form 8050-3, Certification of Aircraft Registration.
( ) ( )
YES NO I enclosed a three-view drawing or photographs of the aircraft.
( ) ( )
YES NO I have weighed the aircraft to determine the most forward and aft center of gravity positions are within the
( ) ( ) established limits. A copy of the weight and balance report is included with this letter.
YES NO The marking requirements of 14 CFR § 45 have been complied with; including permanent attachment of a
( ) ( ) fireproof identification (data) plate, permanent applications of appropriate registration marks and the word
“EXPERIMENTAL” displayed near each entrance to the cabin or cockpit.
YES NO The following placard is displayed in the cockpit in full view of all occupants (not required for single place
( ) ( ) 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
( ) ( ) 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 §
( ) ( ) 91.9
YES NO An Emergency Locator Transmitter (ELT) has been installed, if required, per 14 CFR § 91.207
( ) ( )
YES NO The powerplant installation has undergone at least one hour of ground operation at various speeds from idle to full
( ) ( ) 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 I am requesting my operating limitations to permit aerobatics flight.
( ) ( )
YES NO I am a current Basic Flight Instructor and I am requesting the rights to instruct in this aircraft until January 21,
( ) ( ) 2010.
YES NO This aircraft as a Type Certificated (TC) engine/propeller combination?
( ) ( ) 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?
( ) ( )
YES NO THE FOLLOWING STATEMENT OF SIMILARLY WORDED STATEMENT HAS BEEN RECORDED and
( ) ( ) 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 _________________________________________________________
__________________________________________________
I understand that contact will be made within 10 days of receipt of this letter.
My residence telephone number is: ( )
My daytime business telephone number is: ( )
SIGNED: ____ __________________________________________Owner
Date _______