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<table border="0" cellpadding="2" cellspacing="3" style="width:100%;">
	<tbody>
		<tr>
			<td><span class="titre_p" style="font-family:ITCAvantGardePro;font-size:18px;font-weight:900;">Chauffage</span></td>
		</tr>
		<tr>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Type de chauffage :</span></td>
		</tr>
		<tr>
			<td>{% textarea_tag name=&quot;8cfc6818&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Type de chauffage&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Type de chauffage&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td style="vertical-align: bottom;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Descriptif de l&rsquo;installation :</span></td>
		</tr>
		<tr>
			<td>{% textarea_tag name=&quot;0c63d155&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Descriptif de l&#39;installation&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Descriptif de l&#39;installation&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="1" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 10%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Chaudi&egrave;re :</span></td>
			<td>{% textinput_tag name=&quot;64f7cfe3&quot; data_label=&quot;Type de chaudi&egrave;re&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Type de chaudi&egrave;re&quot; maxlength=&quot;45&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="text-align: right; vertical-align: middle; width: 7%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Ann&eacute;e </span>:</td>
			<td style="width: 7%;">{% textinput_tag name=&quot;5595ac1a&quot; data_label=&quot;Ann&eacute;e&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Ann&eacute;e&quot; maxlength=&quot;4&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="1" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 30%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Le fonctionnement est-il satisfaisant : </span></td>
			<td>{% textinput_tag name=&quot;a61c47ce&quot; data_label=&quot;Fonctionnement&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Fonctionnement&quot; maxlength=&quot;75&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 15%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Eau chaude par : </span></td>
			<td>{% textinput_tag name=&quot;51fe0b62&quot; data_label=&quot;Eau chaude&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Eau chaude&quot; maxlength=&quot;70&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 15%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Ventilation par :</span></td>
			<td>{% textinput_tag name=&quot;db8f683e&quot; data_label=&quot;Ventillation&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Ventillation&quot; maxlength=&quot;70&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 15%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><span class="titre_p" style="font-size: 18px; font-weight: 900;">&Eacute;lectricit&eacute; :</span> &nbsp;</span></td>
			<td>{% textinput_tag name=&quot;64a80f37&quot; data_label=&quot;&Eacute;lectricit&eacute;&quot; data_map_field=&quot;nomap&quot; data_help=&quot;&Eacute;lectricit&eacute;&quot; maxlength=&quot;70&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 38%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Date d&rsquo;installation ou de derni&egrave;re r&eacute;fection : </span></td>
			<td>{% textinput_tag name=&quot;450484c4&quot; data_label=&quot;Derni&egrave;re r&eacute;fection&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Derni&egrave;re r&eacute;fection&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 30%;"><span class="titre_p" style="font-family:ITCAvantGardePro;font-size:18px;font-weight:900;">Plomberie / sanitaire :</span></td>
			<td>{% textinput_tag name=&quot;95665a2d&quot; data_label=&quot;Plomberie sanitaire&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Plomberie sanitaire&quot; maxlength=&quot;60&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 38%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Date d&rsquo;installation ou de derni&egrave;re r&eacute;fection : </span></td>
			<td>{% textinput_tag name=&quot;76e5a821&quot; data_label=&quot;Derni&egrave;re r&eacute;fection&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Derni&egrave;re r&eacute;fection&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td><span class="titre_p" style="font-family:ITCAvantGardePro;font-size:18px;font-weight:900;">D&eacute;pendances et annexes :</span></td>
		</tr>
		<tr>
			<td>{% textarea_tag name=&quot;bafd70fd&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;D&eacute;pendances et annexes&quot; data_map_field=&quot;nomap&quot; data_help=&quot;D&eacute;pendances et annexes&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

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