<!-- Begin Body --> 
<form  role="form" id="construction_and_utilities_form" class="form-horizontal">
	<div class="container-fluid" style="padding-top:120px; height:auto">
		<div class="row"><br/></div> 
		<div class="row">
			<div class="col-lg-1 col-md-1 col-sm-1 col-xs-12 center"></div> 
			<div class="col-lg-10 col-md-10 col-sm-10 col-xs-12 center"> 
				<fieldset> 
					<div class="form-group">
						<label class="col-md-1 text-left" for="block"><small>Block</small></label>
						<div class="col-md-1">
							<input  type="text" id="block" placeholder="Block" readonly value="" class="form-control text-left" name="block">
						</div> 
						
						<div class="col-md-1"></div>

						<label class="col-md-1 text-left" for="lot"><small>Lot</small></label>
						<div class="col-md-6">
							<input  type="text" id="lot" placeholder="Lot" value="" readonly class="form-control text-left" name="lot">
						</div>

						<div class="col-md-4"></div>
					</div> 
				</fieldset>


				<fieldset class="well"> 
					<h3>Construction and Utilities</h3>
					<br/><br/>
					<div class="form-group">					 
						<div class="col-md-2 text-center center">
							<input  type="checkbox" value="yes" id="road" class="text-left left " name="road">
						</div> 
						<label class="col-md-4 text-left left " for="road"><small>Road</small></label>
					</div>	

					<div class="form-group">
						<div class="col-md-2 text-center center">
							<input  type="checkbox" value="yes" id="side_walk" class="text-left left " name="side_walk">
						</div>
						<label class="col-md-4 text-left left " for="side_walk"><small>Side Walk & Gutter</small></label>	 
					</div> 

					<div class="form-group">
						<div class="col-md-2 text-center center">
							<input  type="checkbox" value="yes" id="meralco" class="text-left left " name="meralco">
						</div>
						<label class="col-md-4 text-left left " for="meralco"><small>Meralco</small></label>	 
					</div> 

					<div class="form-group">
						<div class="col-md-2 text-center center">
							<input  type="checkbox" value="yes" id="water" class="text-left left " name="water">
						</div>
						<label class="col-md-4 text-left left " for="water"><small>Water</small></label>	 
					</div> 

					<div class="form-group">
						<div class="col-md-2 text-center center">
							<input  type="checkbox" value="yes" id="house_construction" class="text-left left " name="house_construction">
						</div>
						<label class="col-md-2 text-left left " for="house_construction"><small>House Construction</small></label>
						<div class="col-md-2">
							<input  type="text" value="" placeholder="%" id="house_construction_percentage" class="form-control text-right right " name="house_construction_percentage">
						</div>	 
					</div>   
				</fieldset>
			</div> 
		</div>
		<div class="row"><br/></div>
	</div>
</form>


