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						<td style="width: 7%;">&nbsp; 1 |</td>
						<td>Situation 
						et d&eacute;signation du bien</td>
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&nbsp;

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						ADRESSE : 
						{% textarea_tag name=&quot;e57f51de&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Adresse du bien&quot; data_map_field=&quot;full_address&quot; data_help=&quot;Adresse du bien&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}
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						<td colspan="5" style="padding: 5px; border-color: rgb(165, 100, 75);">D&Eacute;SIGNATION SUCCINCTE :</td>
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						<td style="padding: 5px; border-color: rgb(165, 100, 75); width: 33%;">Nb de pi&egrave;ces :&nbsp;{% select_tag name=&quot;fb38fc60&quot; data_label=&quot;Nb de pi&egrave;ces&quot; data_map_field=&quot;nomap&quot; data_choices=&quot;choix|choix; studio|studio; 1|1; 2|2; 3|3; 4|4; 5|5; 6|6; 7|7; 8|8; 9|9; 10|10; 11|11; 12|12; 13|13; 14|14; 15|15;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
						<td colspan="2" style="padding: 5px; border-color: rgb(165, 100, 75); width: 33%;">&Eacute;tage : {% select_tag name=&quot;6bf42d4e&quot; data_label=&quot;Etage&quot; data_map_field=&quot;floor&quot; data_choices=&quot;choix|choix; RDC|RDC; 1er|1er; 2e|2e; 3e|3e; 4e|4e; 5e|5e; 6e|6e; 7e|7e; 8e|8e; 9e|9e; 10e|10e; 11e|11e; 12e|12e; 13e|13e; 14e|14e; 15e|15e;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
						<td colspan="2" style="padding: 5px; border-color: rgb(165, 100, 75); width: 33%;">Lot(s) n&deg; : {% textinput_tag name=&quot;f512b972&quot; data_label=&quot;Lot n&deg;&quot; data_map_field=&quot;parcel_numero&quot; maxlength=&quot;10&quot; style=&quot;max-width:100px;min-width:100px;width:100px;&quot; fixedwidth=&quot;100&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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						<td colspan="5" style="padding: 5px; border-color: rgb(165, 100, 75);">{% textarea_tag name=&quot;ffac3124&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;D&eacute;signation succincte&quot; data_map_field=&quot;realty_name&quot; data_help=&quot;D&eacute;signation succincte&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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						<td colspan="2" rowspan="1" style="padding: 5px; border-color: rgb(165, 100, 75); width: 50%;">{% checkbox_tag name=&quot;a263537f&quot; data_label=&quot;Surface Carrez&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Superficie loi Carrez &quot; %}&nbsp;Surface Carrez :&nbsp;{% textinput_tag name=&quot;ed0bee5c&quot; data_label=&quot;Surface Carrez&quot; data_map_field=&quot;area&quot; data_help=&quot;Surface de vente&quot; maxlength=&quot;7&quot; style=&quot;max-width:60px;min-width:60px;width:60px;&quot; fixedwidth=&quot;60&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %} m&sup2; environ</td>
						<td colspan="3" rowspan="1" style="padding: 5px; border-color: rgb(165, 100, 75); width: 50%;">{% checkbox_tag name=&quot;d1b440a8&quot; data_label=&quot;Surface au sol&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Surface au sol&quot; %}&nbsp;Surface au sol :&nbsp;{% textinput_tag name=&quot;c0f7e094&quot; data_label=&quot;Surface r&eacute;serve&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Surface au sol&quot; maxlength=&quot;7&quot; style=&quot;max-width:60px;min-width:60px;width:60px;&quot; fixedwidth=&quot;60&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %} m&sup2;&nbsp;environ</td>
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						<td colspan="5" style="padding: 5px; border-color: rgb(165, 100, 75);">&Eacute;quipements d&rsquo;acc&egrave;s aux technologies de l&rsquo;information et de la communication :&nbsp;{% checkbox_tag name=&quot;1b00d1c2&quot; data_label=&quot;ADSL&quot; data_map_field=&quot;nomap&quot; %}&nbsp;ADSL&nbsp; &nbsp; {% checkbox_tag name=&quot;60c96ed8&quot; data_label=&quot;Fibre&quot; data_map_field=&quot;nomap&quot; %} Fibre</td>
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						<td colspan="5" style="padding: 5px; border-color: rgb(165, 100, 75); text-align: justify;">D&eacute;claration du bailleur : le bien, objet des pr&eacute;sentes, a-t-il subi un sinistre ayant donn&eacute; lieu au versement d&rsquo;une indemnit&eacute; d&rsquo;assurance garantissant les risques de catastrophes naturelles ou technologiques, vis&eacute;es &agrave; l&rsquo;art. L. 125-2 du Code des Assurances :&nbsp; {% checkbox_tag name=&quot;62fd56ed&quot; data_label=&quot;le bien a-t-il subi un sinistre ayant donn&eacute; lieu au versement d&rsquo;une indemnit&eacute; d&rsquo;assurance ? oui&quot; data_map_field=&quot;nomap&quot; %}&nbsp;Oui&nbsp; &nbsp;{% checkbox_tag name=&quot;b159bc3a&quot; data_label=&quot;le bien a-t-il subi un sinistre ayant donn&eacute; lieu au versement d&rsquo;une indemnit&eacute; d&rsquo;assurance ? Non&quot; data_map_field=&quot;nomap&quot; data_checked=&quot;true&quot; %} Non</td>
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						<td colspan="5" style="padding: 5px; border-color: rgb(165, 100, 75);">LOCAL PRINCIPAL :&nbsp; {% radio_tag name=&quot;c24db33e&quot; data_label=&quot;Type de local&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Type de local&quot; data_choices=&quot;Appartement&nbsp; &nbsp;|Appartement; Maison&nbsp; &nbsp;|Maison; Local commercial&nbsp; &nbsp;|Local commercial;&quot; %}</td>
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						<td colspan="5" style="padding: 5px; border-color: rgb(165, 100, 75);">USAGE :&nbsp; {% radio_tag name=&quot;4865ec05&quot; data_label=&quot;Usage&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Usage&quot; data_choices=&quot;Habitation&nbsp; &nbsp; |Habitation; Mixte&nbsp; &nbsp; |Mixte; Professionnel&nbsp; &nbsp; |Professionnel; Commercial&nbsp; &nbsp; |Commercial;&quot; %}</td>
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						<td colspan="5" style="padding: 5px; border-color: rgb(165, 100, 75);">ANNEXES :&nbsp; &nbsp;{% checkbox_tag name=&quot;0fcfa0bf&quot; data_label=&quot;Garage&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Garage&quot; %} Garage n&deg; {% textinput_tag name=&quot;a4138xab&quot; data_label=&quot;n&deg; garage&quot; data_map_field=&quot;nomap&quot; data_help=&quot;n&deg; garage&quot; maxlength=&quot;4&quot; style=&quot;max-width:35px;min-width:35px;width:35px;&quot; fixedwidth=&quot;35&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}&nbsp; &nbsp; &nbsp;|&nbsp; &nbsp;{% checkbox_tag name=&quot;0fxfx0bf&quot; data_label=&quot;Place de stationnement&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Place de stationnement&quot; %}&nbsp;Place de stationnement n&deg; {% textinput_tag name=&quot;a4138xxb&quot; data_label=&quot;n&deg; Place de stationnement&quot; data_map_field=&quot;nomap&quot; data_help=&quot;n&deg; Place de stationnement&quot; maxlength=&quot;4&quot; style=&quot;max-width:35px;min-width:35px;width:35px;&quot; fixedwidth=&quot;35&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}&nbsp; &nbsp; |&nbsp; &nbsp;{% checkbox_tag name=&quot;0fcfx0bf&quot; data_label=&quot;Cave&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Cave&quot; %}&nbsp;Cave n&deg; {% textinput_tag name=&quot;a4138dab&quot; data_label=&quot;n&deg; cave&quot; data_map_field=&quot;nomap&quot; data_help=&quot;n&deg; cave&quot; maxlength=&quot;4&quot; style=&quot;max-width:35px;min-width:35px;width:35px;&quot; fixedwidth=&quot;35&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}&nbsp;</td>
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